Post on 04-Apr-2018
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
1/8
Osteomyelitis: Always aDiagnostic Puzzle page 1 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis
Always a Diagnostic
Puzzle
schreibman.info Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: Put the Pieces Together
+GdAbscess
RADIOGRAPHSRecent
HISTORY
ClinicalSurgical
MRIMarrow
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: TopicsDefinitionsActiveChronic
MechanismsHematogenousDirect spread
Imaging
RadiographsMRI
Bone Model
Cortex
Marrow
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: Definitionscomes from Greek:
osteon= bonemyelos= marrow itis = inflammation
Inflammation of bone marrowInfection of bone marrow
MRIMarrow
High SensitivityLow Specificity
Marrow inflammationfrom infection lookslike inflammationfrom any other cause
Osteomyelitis
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: DefinitionsActiveOsteomyelitis
vs
ChronicOsteomyelitis
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: DefinitionsActiveOsteomyelitisAggressive
Resembles TumorCortex DestructionPeriosteal Reaction
http://www.schreibman.info/http://www.schreibman.info/http://d/SchreibmanHandouts/HI.ppthttp://www.schreibman.info/7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
2/8
Osteomyelitis: Always aDiagnostic Puzzle page 2 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
ActiveOsteomyelitis 16yoM distal fibula pain3w after inversion injury
HISTORY
Clinical Followup
AggressiveCortex DestructionPeriosteal Reaction
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: DefinitionsChronicOsteomyelitisNon-AggressiveResembles Callus
3 Characteristics:Involucrum: wrap
Thick periosteum around infected bone
Sequestrum: set apartPiece of dead, infected, boneCloaca: sewer
Opening in cortex throughwhich pus can escape
RADIOGRAPHS
Active Chronic
Ken L Schreibman, PhD/MD 2009 schreibman.info
Activevs ChronicOsteomyelitis
RADIOGRAPHS
Active Chronic
ActiveOsteomyelitis
ChronicOsteomyelitis
Ken L Schreibman, PhD/MD 2009 schreibman.info
ActiveOsteomyelitisAggressiveCortex DestructionPeriosteal Reaction
16yoM distal fibula pain3w after inversion injury
ActiveOsteomyelitis
Ken L Schreibman, PhD/MD 2009 schreibman.info
ChronicOsteomyelitis 19yoM fibula pain2.5years later
2.5 years
Chronic
Osteomyelitis
RADIOGRAPHS
Active Chronic
Ken L Schreibman, PhD/MD 2009 schreibman.info
ChronicOsteomyelitis 19yoM fibula pain2.5years later
Chronic
OsteomyelitisInvolucrum
Sequestrum
Cloaca
CT
Fibula
Tibia
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
3/8
Osteomyelitis: Always aDiagnostic Puzzle page 3 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
ChronicOsteomyelitis
6 weeks later
Involucrum Developing
42yoM Diabetic
10 more weeksKen L Schreibman, PhD/MD 2009 schreibman.info
27yoM s/p removalRt Femoral RodChronicOsteomyelitis
Involucrum
27yoM s/p removalRt Femoral Rod
CT Scout
Ken L Schreibman, PhD/MD 2009 schreibman.info
27yoM s/p removalRt Femoral RodChronicOsteomyelitis
InvolucrumSequestrum
27yoM s/p removalRt Femoral Rod
CT Scout
Axial Slice
Coronal ReformatKen L Schreibman, PhD/MD 2009 schreibman.info
27yoM s/p removalRt Femoral RodChronicOsteomyelitis
InvolucrumSequestrumCloaca
27yoM s/p removalRt Femoral Rod
CT Scout
Axial Slice
Oblique Coronal
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MechanismsDirect Spread adjacent tissuesMost common cause
Decubitus ulcerSeptic arthritis
Ken L Schreibman, PhD/MD 2009 schreibman.info
Decubitus Ulcer Ischium
Ischium Ischium
T1
52yoMquadriplegic
T1
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
4/8
Osteomyelitis: Always aDiagnostic Puzzle page 4 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MechanismsDirect Spread adjacent tissuesMost common causeDecubitus ulcer
Septic arthritisPuncture into boneStepped on nailExternal fixatorRing sequestrum
Ring SequestrumChronicOsteomyelitis
InvolucrumSequestrumCloacaPoor Union
RADIOGRAPHS
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MechanismsDirect Spread adjacent tissuesMost common causeDecubitus ulcerSeptic arthritis
Puncture into boneStepped on nailExternal fixatorRing sequestrum
HematogenousSite related to patient age
Ken L Schreibman, PhD/MD 2009 schreibman.info
Hematogenous OsteomyelitisSite related to patient age
MatureBone
ImmatureBone
PhysisEpiphysis
Metaphysis
Diaphysis
Arteriole
Venule
BloodSupply
Septic
Emboli
Infectionoccursat end
of
Infectionoccurs atmetaphysis
of
Ken L Schreibman, PhD/MD 2009 schreibman.info
Hematogenous Osteomyelitis1yoM streppneumonia
Ken L Schreibman, PhD/MD 2009 schreibman.info
Hematogenous Osteomyelitis1yoM streppneumonia
3 months later
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
5/8
Osteomyelitis: Always aDiagnostic Puzzle page 5 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: ImagingMany Imaging Options:RadiographsCT
MRUSNuc Med
What to order when?
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: What to Order WhenALWAYS!
May show evidence of active infectionBone destruction, periosteal reaction
May show evidence of chronic infection
InvolucrumScreen for metalOrthopedic hardware, foreign bodies
Unexpected findingsFractures,
Delineate current anatomySurgical resections,
RADIOGRAPHS NEED TO BE RECEN
vs
Radiographs
gas in soft tissues
neuropathic deformity
Ken L Schreibman, PhD/MD 2009 schreibman.info
66yoM h/o DiabetesPresents in Sept swollen footMR is requested to r/o Osteo
Are there radiographs?Yes
3 months ago
Repeat radiographs obtained
now, prior to MR, reveal
Need for Recent Radiographs Example
June September
Neuropathic destructionof the Lisfranc joint
NormalLisfranc joint
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: What to Order WhenRadiographsALWAYS!CT. Chronic CasesCT best for calcified structures InvolucrumSequestrumCloaca
CT of the extremities is insensitive for:Bone marrow pathologySoft tissue pathology
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: What to Order WhenRadiographsALWAYS!CT. Chronic Cases
MRI...Active CasesShows extent of soft tissue edemaExcellent for demonstrating abscesses
and other drainable fluid collectionsSensitive for bone marrow pathologyCan be overlysensitive
at expense of specificity Infected bone marrow resembles
marrow edema due to other causes
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR Imaging
T1 T2fsSurrounding
Tissues
(fat)
CortexMarrow
CortexMarrow
Surrounding
Tissues
(fat)
Bone Model
X-rays
CortexMarrow
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
6/8
Osteomyelitis: Always aDiagnostic Puzzle page 6 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR ImagingPath=FluidT1=DarkT2=Bright
T1fs+GdEnhancement Inflamed UniformAbscessWallCyst NotT1
(STIR)T2fs
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR Imaging
T1T1fs(STIR)
T2fs
+Gd
EnhancementInflamed UniformAbscessWallCyst Not
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR ImagingDetection of the non-enhancingpus pocket (abscess) is crucialPresence of soft tissue abscess
proves the edema in underlyingbone marrow is osteomyelitis.
Site for aspiration for culture.
If IV Gd doesnt get into abscess,IV antibiotics wont get in either,abscess may require drainage.
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR Imaging63yoM Diabeticwith heel ulcer
T1
IR
MinimalMarrowEdema
T1fsIVGd
Enhancing cellulitisNo non-enhancing
abscess pocket
Intact cortex
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR Imaging63yoM Diabetic2 weeks later
Intact cortex
2 weeks earlier
Corticaldestruction
IRT1fs
IVGd
More marrow edemaMore tissue edema
Non-enhancingabscess pocket
Ken L Schreibman, PhD/MD 2009 schreibman.info
Intact cortex
2 weeks earlier
Corticaldestruction
Osteomyelitis: MR Imaging63yoM Diabetic2 weeks later
T1T1fs
IVGdIR
Marrow edema
Abscess Pocket
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
7/8
Osteomyelitis: Always aDiagnostic Puzzle page 7 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
Decubitus Ulcer Ischium
T1
52yoMquadriplegic
T2fs
Abscess?
Abscess!
T1fs+Gd
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR Imaging1yoF Swollenleft lower leg
R L Periosteal Reaction
Metaphyseallucency
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: MR Imaging1yoF Swollenleft lower leg
T1T1fs
IVGdT2fs
Periosteal Reaction
MetaphysealNon-enhancingabscess
Intra-osseous
Brodie Abscess
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: What to Order WhenRadiographsALWAYS!CT. Chronic CasesMRI...Active CasesUS.Fluid/AbscessUS guided aspiration for cultureCannot assess bone involvement
Nuc Med.. Problem CasesWhere MR specificity is decreasedNeuropathic feet Infected hardware
Ken L Schreibman, PhD/MD 2009 schreibman.info
Infection around metal: MRI
T,K 21yoM
T2fs T1fsIVGd
We canseesoft tissues
around bone
Enhancing
granulation tissue(phlegmon?)
We cantsee the marrow within boneCannot evaluate for osteomyelitis
Ken L Schreibman, PhD/MD 2009 schreibman.info
Infection around metal: Nuc MedRequires 2 Radiopharmaceuticals
1)Tc-Bone Scan(Active bone metabolism)
2)In-WBC Scan(Areas of WBC accumulation)
1)BS: Sen/Spec2)WBC:Spec/Sen
7/30/2019 Dificultati Si Diagn.diferential Osteomielita Acuta
8/8
Osteomyelitis: Always aDiagnostic Puzzle page 8 of 8
Ken L Schreibman, PhD/MD 1/30/10 www.schreibman.info
Ken L Schreibman, PhD/MD 2009 schreibman.info
Infection around metal: Nuc Med
Femur
Tibia
Femur
Tibia
S,B 31yoM
Tc-Bone Scan In-WBC Scan RemovedTibia Plate
PlacedAntibiotic
PMM-BeadsTibiaPlate
FemurPlate
Ken L Schreibman, PhD/MD 2009 schreibman.info
Charcot (Neuropathic) Foot
P,K 65yoF
T1 T2fsT1fs+IV Gd
Tc99m MDP In111 WBC
Abscess
Infection
Ken L Schreibman, PhD/MD 2009 schreibman.info
Osteomyelitis: Put the Pieces Together
+GdAbscess
RADIOGRAPHSRecent
HISTORY
ClinicalSurgical
MRIMarrow