THE RADIOLOGY OF OSTEOMYELITIS

GRAND ROUND PRESENTATION NBU PRESENTED BY: Dr. ALFRED ODHIAMBO

RADIOLOGIST PLAZA IMAGING SOLUTIONS LECTURER THE UNIVERSITY OF NAIROBI

The background
Understanding the blood supply to bone is key to the comprehension of the varied age related faces of osteomyelitis. The blood supply to a long bone is via 1. Nutrient artery :This is the major source of blood throughout life supplying the marrow and inner cortex. 2. Periosteal vessels : They supply the outer cortex. 3. Metaphyseal and epiphyseal vessels.

Entry of microorganisms
Micro-organisms may infect any of the tissues of the musculoskeletal system where they cause similar symptom complexes of pain loss of function variably accompanied by fever systemic illness.

Blood supply variations

In the infant ,vessels penetrate the epiphyseal plate in both directions. Metaphyseal infections can thus pass to the epiphysis and subsequently result in joint infection. The periosteum is loose and easily stripped. In childhood between 2 and 16 years few vessels cross the epiphyseal plate although the periosteum is still loose. Epiphyseal and joint infections are less frequent. In adults epiphyseal closure reconnects epiphyseal and metaphyseal circulations. However periosteum is firmly bound down and

In summary

 The formation of pus in bone deprives local cortex and medulla of its blood supply. Dead bone is resorbed by granulation tissue. Pieces of dead bone especially if cortical or surrounded by pus are not resorbed and remain as sequestra. The devitalized sequestra remain dense while the surrounding vital bones become demineralized due to hyperaemia. Involucrum ( new bone) forms under intact perioteum elevated by pus In areas of dead periosteum defects in the involucrum occur called cloacae which allow pus and sequestra to escape. May cause sinus track to the skin.

Pathological changes in osteomyelitis

Early changes at imaging

Most findings are subtle and often missed. Good quality films will show deep soft tissue swelling with displacement of adjacent muscle planes by day 2. On day 3 to 4 while osseous structures still look normal muscle mass may appear increased. Plane between muscle and subcutaneous tissues becomes blurred. At this time US, MRI and nuclear imaging are most informative. Destructive bone changes of acute osteomyelitis with periosteal elevation are not seen until 10 to 14 days after infection.

What is special in the neonate

The destructive processes are florrid in the neonate owing to the fast spread of infection through the spongiosa and cortex. Localized metaphyseal rarefaction rapidly progresses to irregular destruction with the formation of spicules of remaining bone

 Neonatal OM: Due to presence of transphyseal vessels allowing spread of organisms into the growth plate and later joint space . In the infant systemic response to bone infection is compromised . One may only see STS, tenderness and functional loss. Antibiotic modified OM may result in delay in diagnosis. Chronic multifocal OM: Less aggressive with little or no periosteal elevation and associated with plantopalmar pustulosis. Sclerosing osteomyelitis of Garre: Sclerosis is gross with absence of apparent bone destruction. dD OO Brodies abscess: Is a localized OM usually seen in cancellous bone . A circumscribed destructive lesion is surrounded by sclerosis. Simulates OO especially when there is sequestrum formation

Unique forms of OM

Early OM

OM of CT

OM in the forearm

Imaging tools at work

COM

Sclerosing OM of Garres

Brodies abscess at MR

Bites are lethal

And now our patient

The images follow

OSTEOMYELITIS IMAGE -1

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THE END

THANKS