Imaging of Osteomyelitis in Children

https://doi.org/10.1016/S0033-8389(05)70276-1Get rights and content

Infection of the pediatric musculoskeletal system still constitutes a diagnostic and therapeutic challenge.26 Antibiotic therapy has a high success rate in most bacterial infections. Key elements are the route of administration of the antibiotics and the duration of treatment. Diagnostic imaging accuracy has improved with the proper use of guidelines in the choice of the emerging modalities.11, 27, 37 Osteomyelitis, however, is a multifaceted disease, according to the age of the patient, site of infection, and the type of clinical setting (immunosuppressed patient, sickle cell disease, and so forth). Diagnostic pitfalls are occasionally encountered and often leukemia or neuroblastoma may mimic osteomyelitis. An early diagnosis of skeletal infection is important, otherwise sequelae may result.6

With the advent of scintigraphy, sonography, CT, and MR imaging, the imaging approach to osteomyelitis is not simple but the results are more accurate. Factors, such as the need for sedation, radiation exposure, and cost, cannot be dismissed. Selection of the optimal technique is essential for obtaining the diagnostic information needed.

Following a brief review of the physiopathology of osteomyelitis, the different imaging modalities are presented with a focus on their potential values. The classical presentations, and some more specific clinical scenarios, are described along with considerations of differential diagnosis.

Section snippets

Physiopathology

Osteomyelitis is by definition an infection of the bone and bone marrow.56 Infective or suppurative osteitis is limited to the cortical bone. An infective periostitis refers to the contamination of the periosteal cloak around the bone. Septic (infectious) arthritis, when a joint is involved, is a surgical emergency in children. Three different clinical entities may be identified: (1) acute, (2) subacute, and (3) chronic osteomyelitis. This nosology relies on many factors, among which the host

Acute Osteomyelitis.

Typical clinical signs include the triad of fever, local pain, and tenderness. In many cases, only an elevated sedimentation rate and local tenderness are present. Bone destruction is radiographically evident about 2 weeks after the onset of the infection. Characteristic features are the metaphyseal location in the long bones and the periosteal reaction. The latter may be seen, however, in histiocytosis, leukemia, trauma, or Ewing's sarcoma (Figs. 5 and 6).2, 5, 9, 40

Subacute Osteomyelitis.

It has a more insidious

COMPLICATIONS OF OSTEOMYELITIS

Secondary septic (infectious) arthritis and possible dislocation occur when the infected metaphysis is intracapsular as is the case for the hip. A recent survey has shown an appreciable incidence of joint involvement in limb osteomyelitis with a 33% incidence of adjacent septic (infectious) joint.53 Pathologic fracture may occur because of the osteopenic early bone destruction or the insufficient involucrum formation.

Growth disturbances include either lengthening of the bone, the result of

Hand.

The infection usually spreads from a puncture wound by three routes: (1) tendon sheath, (2) fascial planes, and (3) lymphatics. S aureus is commonly but not always the causative agent (Fig. 8).

Foot.

Pseudomonas aeruginosa infection involves the calcaneus in cases of puncture wounds and bone changes occur along the inferior cortical margin. Hematogenous osteomyelitis of the calcaneus prefers to develop close to the posterior half of the bone in the metaphyseal equivalent region.55

Metaphyseal Equivalent Osteomyelitis.

Sites of involvement

SUMMARY

Imaging approach to osteomyelitis in children should aim toward a timely and accurate diagnosis in view of the need for prompt therapy to prevent sequelae. One must take advantage of the specific value of each imaging modality and adopt a strategy that works best for a given child in a given institution.

References (74)

  • K. Applegate et al.

    Neuroblastoma presenting clinically as hip osteomyelitis: A “signature” diagnosis on skeletal scintigraphy

    Pediatr Radiol

    (1995)
  • E.M. Azouz et al.

    Imaging for bone and joint infection in children and adults

    Curr Orthop

    (1994)
  • E.M. Azouz et al.

    CT evaluation of primary epiphyseal bone abscesses

    Skelet Radiol

    (1993)
  • L.L. Barton et al.

    Septic arthritis in childhood

    Am J Dis Child

    (1987)
  • K. Blumberg et al.

    Fractures of the cuboid bone in toddlers

    Pediatr Radiol

    (1999)
  • J.M. Bohl et al.

    Mycobacterium tuberculosis sternal osteomyelitis presenting as anterior chest wall mass

    Pediatr Infect Dis J

    (1999)
  • R.D. Boutin et al.

    The SAPHO syndrome: An evolving concept for unifying several idiopathic disorders of bone and skin

    AJR Am J Roentgenol

    (1998)
  • V.P. Chandnani et al.

    Acute experimental osteomyelitis and abscesses: Detection with MR imaging versus CT

    Radiology

    (1990)
  • W. Chiu et al.

    Indium-111-oxine labeled leukocyte uptake in Ki-1 positive anaplastic large cell lymphoma

    Pediatr Radiol

    (1999)
  • J.J. Crowley et al.

    Imaging of sickle cell disease

    Pediatr Radiol

    (1999)
  • G.P. Dalton et al.

    Bone infarction versus infection in sickle cell disease in children

    J Pediatr Orthop

    (1996)
  • B.C. Dangman et al.

    Osteomyelitis in children: Gadolinium-enhanced MR Imaging

    Radiology

    (1992)
  • E.M. Delfaut et al.

    Fat suppression in MR Imaging: Techniques and pitfalls

    Radiographics

    (1999)
  • G.A. Demopulos et al.

    Role of radionuclide imaging in the diagnosis of acute osteomyelitis

    J Pediatr Orthop

    (1988)
  • M.S. Dhillon et al.

    Tuberculosis of the patella

    Skeletal Radiol

    (1998)
  • M. Dietlein et al.

    The fibrous metaphyseal defect in early stage differential diagnosis to metaphysitis

    Pediatr Radiol

    (1992)
  • A.S. Doria et al.

    Bony involvement in paracoccidioidomycosis

    Pediatr Radiol

    (1997)
  • W.A. Erdman et al.

    Osteomyelitis: Characteristics and pitfalls of diagnosis with MR imaging

    Radiology

    (1991)
  • R. Gold

    Diagnosis of osteomyelitis

    Pediatr Rev

    (1991)
  • R.H. Gold et al.

    Bacterial osteomyelitis: Findings on plain radiography, CT, MR, and scintigraphy

    AJR Am J Roentgenol

    (1991)
  • D. Grier et al.

    Osteomyelitis in hospitalized children with chickenpox: Imaging findings in four cases

    AJR Am J Roentgenol

    (1993)
  • A. Hammou et al.

    L'échographie dans les infections osseuses

    Journal d'Echographie et de Medecine par Ultrasons

    (1997)
  • H.T. Harcke

    Role of imaging in musculoskeletal infections in children

    J Pediatr Orthop

    (1995)
  • M.P. Hauer et al.

    Comparison of turbo inversion recovery magnitude (TIRM) with T2-weighted turbo spin-echo and T1-weighted spin-echo MR imaging in the early diagnosis of acute osteomyelitis in children

    Pediatr Radiol

    (1998)
  • F.A. Hoffer et al.

    Percutaneous drainage of subperiosteal abscess: A potential treatment for osteomyelitis

    Pediatr Radiol

    (1998)
  • A.W. Howard et al.

    Reduction in osteomyelitis and septic arthritis related to Haemophilus influenzae type B vaccination

    J Pediatr Orthop

    (1999)
  • C.B. Howard et al.

    Ultrasound in diagnosis and management of acute haematogenous osteomyelitis in children

    J Bone Joint Surg Br

    (1993)
  • Cited by (73)

    • More than an achy back: Spinal epidural abscess

      2021, Pediatric Imaging for the Emergency Provider
    • I feel it in my bones: Osteomyelitis

      2021, Pediatric Imaging for the Emergency Provider
    • Radionuclide Imaging of Infection and Inflammation in Children: a Review

      2018, Seminars in Nuclear Medicine
      Citation Excerpt :

      Plain films are notoriously insensitive in the detection of acute osteomyelitis. While soft tissue swelling may be seen shortly after the onset of symptoms, changes in bone are rarely appreciated before 7-10 days and are further delayed when disease involves the spine or pelvis.64,65 However, plain films are often used to exclude other diagnostic entities such as tumor or trauma.56

    • Nuclear Medicine Imaging in Pediatric Infection or Chronic Inflammatory Diseases

      2017, Seminars in Nuclear Medicine
      Citation Excerpt :

      Therefore, further diagnostic imaging is usually required, and each modality has its advantages and limitations. Plain radiographs are often the first imaging choice, but bone destruction only becomes apparent 2-3 weeks after the symptom onset.14 A negative plain radiograph on admission does not rule out OM, but can exclude other pathologic conditions.15

    View all citing articles on Scopus

    Address reprint requests to Kamaldine Oudjhane, MD, MSc, Montréal Children's Hospital, Room C-312, 2300 Tupper Street, Montréal, QC, H3H 1P3 Canada

    *

    Department of Radiology, Faculty of Medicine, McGill University Health Centre, Montréal Children's Hospital; and Shriners Hospital for Children, Montréal, Québec, Canada

    View full text