Dr.

Donny Susilawardhon SpRad

 Musculoskeletal Infection
 Osteomyelitis – Bone
 Infectious Arthritis – Joint
 Cellulitis – Soft tissue
VASCULAR ANATOMY
 Osteomyelitis - Basic Mechanism

 Hematogenous
 Contiguous Source
 Direct
Implantation
 Kronologis
 Radiologis pada awal-awal infeksi tulang adalah soft
tissue edema dan hilangnya fascial planes (sekitar 24
sd 48 jam setelah infeksi)
 7-10 hari setelah infeksi : destructive lytic lesion
(positive radionuclide bone scan)
 2 – 6 minggu : destruksi progressif pada korteks dan
medulla; serta endosteal sclerosis yang
mengindikasikan reactive new bone formation dan
periosteal reaction
 6- 8 minggu : sequestra (mengindikasi necrotic bone)
yang dikelilingi dense involucrum, yang menunjukkan
periosteal new bone
Acute Ostemyelitis
Destruksi korteks
dan periosteal new
bone formation

Adam Greenspan
Infectious Arthritis
vertebra
Infectious Arthritis
Infectious Arthritis
Cellulitis
Cellulitis
 Introduksi
 Merupakan bone abscess yang digambarkan sebagai
sebuah “localized primary purulent collection and a
sclerotic wall”.
 Merupakan bentuk subacute process
 Merupakan bentuk yang lebih sering dijumpai dibanding
bentuk acute
 Extremitas Inferior lebih sering dibanding superior dan
tibia merupakan tulang dengan insiden terbanyak; juga
carpal and tarsal bones
 Semua bagian tulang dapat terkena, tetapi metafise
terbanyak
 History
 Ditemukan oleh Sir Benjamin
Collins Brodie (1783-1862) pada
th. 1832, seorang ahli bedah di
St.George Hospital London UK
 Setelah meng-amputasi kaki
pasien dengan nyeri yang
intractable beberapa tahun
 Pasien meninggal ok infeksi
 Pemeriksaan macrocopis
didapatkan :” “a cavity the size of
a walnut filled with dark-colored
pus. The bone immediately
surrounding the cavity was
whiter and harder than the
surrounding bone. The inner
surface of the cavity appeared to
be highly vascular
 Etiologi
 Coagulase-positive Staphylococcus (30-60%).
 Lainnya : Streptococcus, Pseudomonas, Haemophilus
influenzae (lebih jarang setelah widespread
vaccination), dan coagulase-negative Staphylococcus.
 Terdapat peningkatan prevalensi dari Kingella kingae,
a gram-negative coccobacillus, yang dicatat oleh
Lundy and Kehl, terutama pada anak kurang dari 3
tahun sebagai penyebab dari semua type dari infeksi
osteoarticular, termasuk subacute osteomyelitis.[20]
Modified classification of subacute osteomyelitis
Modified classification of subacute osteomyelitis
 Type I is metaphyseal.
 Type Ia is a punched-out central metaphyseal lesion.
 Type Ib is an eccentric metaphyseal cortical erosion.
 Type II is diaphyseal.
 Type IIa is a localized cortical and periosteal reaction.
 Type IIb is a medullary abscess in the diaphysis without cortical destruction but
with onionskin periosteal reaction.
 Type III is epiphyseal.
 Type IIIa is a primary epiphyseal osteomyelitis.
 Type IIIb is a lesion that crosses the epiphysis and involves both the epiphysis
and the metaphysis.
 Type IV is a metaphyseal equivalent.
 Type IVa involves the vertebral body with an erosive or destructive process.
 Type IVb involves the flat bones of the pelvis.
 Type IVc involves the small bones, such as the tarsal bones.
Gambaran Radiologis – Plain Film
 Lytic lesion often in an oval configuration that is
oriented along the long axis of the bone
 Surrounded by thick dense rim of reactive sclerosis
that fades imperceptibly into surrounding bone
 Lucent tortuous channel extending toward growth
plate prior to physeal closure (pathognomonic)
 Periosteal new-bone formation
 +/- adjacent soft-tissue swelling
 May persist for many months
 “Penumbra Sign” - MRI
 Diteliti pada tahun 2011 oleh Afshin Mohammadi, Department of
Diagnostic Radiology, Imam Khomeini Hospital, Urmia University of
Medical Sciences, Urmia, Iran
 The “penumbra sign” is not pathognomonic but a characteristic MRI
feature of subacute osteomyelitis (3-6). It has been reported in cases of
eosinophilic granuloma, chondrosarcoma, benign cystic lesions of the
bone and intraosseous
 It has been showed that the “penumbra sign” on magnetic resonance
(MR) imaging is useful for discriminating subacute osteomyelitis from
other bone lesions (2, 3).
 The penumbra sign is a rim lining of an abscess cavity with higher
signal intensity than that of the main abscess on T1-weighted images.
 This report presents the “penumbra sign” on MR images of a Brodie’s
abscess in the proximal metaphysis of the left tibia. We present this
case of Brodie’s abscess on magnetic resonance imaging (MRI) with
“penumbra sign” differentiating it from malignant bone tumors.
CT scan of the proximal left leg in the same
patient shows a central intramedullary
hypodense cystic lesion with a thick rim of
ossification.
MRI of the same patient; A, T1-weighted TSE sequence reveals the penumbra sign;
B, T2-weighted TSE sequence reveals the penumbra sign; C, MR image STIR-TSE
sequence shows the penumbra sign.