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Acute Hematogenous Osteomyelitis of Children: Assessment of Skeletal Scintigraphy–Based Diagnosis in the Era of MRI

¹ Department of Radiology, Children’s Hospital, Boston, Massachusetts

View larger version (83K): [in a new window]   FIGURE 1. AHO: MRI performed for diagnostic uncertainty. (A) High tracer localization and uptake are shown in right proximal tibial metaphysis on angiographic-, tissue-, and skeletal-phase images of 13-y-old boy. Findings are typical and highly supportive of diagnosis of AHO. (B) Based entirely on clinical concerns, referring orthopedist obtained MRI. Sagittal fast spin echo inversion recovery MR image shows high signal intensity indicative of marrow edema in right proximal tibial epiphysis, metaphysis, and diaphysis. (C) Sagittal T1-weighted MR image after gadolinium administration shows small (<5 mm) nonenhancing regions indicative of intraosseous abscesses in metaphysis. Although these findings are no more specific than those shown by skeletal scintigraphy, combined results of 2 examinations were clinically regarded as confirmatory of AHO. Patient’s symptoms abated and his erythrocyte sedimentation rate returned to normal during treatment with antibiotics.

View larger version (65K): [in a new window]   FIGURE 2. Cuboid fracture: MRI performed for diagnostic uncertainty. (A) Skeletal scintigraphy tissue- and skeletal-phase images of 19-mo-old boy with 2-d history of limp and 1-d history of fever demonstrates high tracer localization and uptake in left cuboid. This finding is most suggestive of cuboid fracture in child of this age. (B) Noting that traumatized bone is susceptible to AHO and that scintigraphic findings are not specific, referring orthopedist requested MRI. Sagittal T1-weighted gadolinium-enhanced MR image demonstrates linear nonenhancing band of low signal intensity indicative of fracture through base of left cuboid. (C) Fracture had not been shown by plain radiographs. Only after bone aspirate and blood cultures showed no growth and after symptoms of viral upper respiratory and gastrointestinal illness had developed was diagnosis of cuboid fracture without AHO believed to be confirmed and antibiotics discontinued. Symptoms resolved after short leg walking cast was placed.

View larger version (148K): [in a new window]   FIGURE 3. Pelvic AHO with soft-tissue abscess. (A) Tissue- and skeletal-phase images show high tracer localization and uptake extending from left anterosuperior to anteroinferior iliac spine of 9-y-old boy. MRI was requested to assess for possible abscess because of pelvic location of presumed AHO. (B) Coronal gadolinium-enhanced fat-suppressed T1-weighted MR image shows enhancement of ilium corresponding to abnormality shown by scintigraphy. Within enhancing region is nonenhancing area consistent with intraosseous abscess (long arrow). Lobulated rim-enhancing abscess is also present in proximal left musculus gluteus minimus adjacent to anterosuperior iliac spine (short arrow). Note that scintigraphic tissue-phase image also shows subtle degree of high soft-tissue tracer localization in this region. Percutaneous abscess drainage was performed.

View larger version (83K): [in a new window]   FIGURE 4. AHO with subperiosteal and intraosseous abscess. (A) Angiographic-, tissue-, and skeletal-phase images show high tracer localization and uptake in distal right tibial metaphysis of 11-y-old boy. (B) After fever and pain continued through 3 d of intravenous antibiotic therapy, MRI was requested to assess for suspected abscess. Sagittal gadolinium-enhanced fat-suppressed T1-weighted MR image shows focal intraosseous nonenhancing areas (short arrows) and periosteal elevation with nonenhancing subperiosteal collection (long arrow). Findings indicated intraosseous and subperiosteal abscesses, which were subsequently drained surgically.