Radiographic Manifestations

The earliest but nonspecific radiographic change of acute osteomyelitis is soft-tissue swelling with the obliteration of the fat plane. It can be detected as early as 3 days after the sudden onset of disease. However, the direct sign of bone infection manifests more than a week later. The initial bone alterations are local os-teopenia and osteolysis typically in the long bone metaphysis. With the rapid progress of the disease, infection spreads rampantly from cancellous bone to cortex and periosteum,

Acute Osteomyelitis

Fig. 6.2A, B Characteristic metaphyseal localization of acute osteomyelitis with the sharp delimitation by phy-seal cartilage. A Anterior pinhole scintigraph of the left proximal femur in a 15-year-old boy with acute osteomyelitis reveals intense tracer uptake localized in the me-taphysis (arrow). Its upper border is sharply demarcated by the physis, which concentrates tracer intensely (arrowheads). B Anteroposterior radiograph shows as yet no radiographic alteration. The physeal barrier is represented by the wavy, linear lucency of cartilage (arrows)

Fig. 6.2A, B Characteristic metaphyseal localization of acute osteomyelitis with the sharp delimitation by phy-seal cartilage. A Anterior pinhole scintigraph of the left proximal femur in a 15-year-old boy with acute osteomyelitis reveals intense tracer uptake localized in the me-taphysis (arrow). Its upper border is sharply demarcated by the physis, which concentrates tracer intensely (arrowheads). B Anteroposterior radiograph shows as yet no radiographic alteration. The physeal barrier is represented by the wavy, linear lucency of cartilage (arrows)

Knee Cartilage Linear Lucency

Fig. 6.3A, B Peripheral osteomyelitis with articular involvement in an adult. A Sunrise view radiograph of the right knee of a 65-year-old female with medial femoral condylar infection shows peripheral osteolysis with localized joint involvement (arrow). B Semilateral pinhole scan reveals an ill-defined patchy area of increased uptake in the medial femoral condyle (arrow)

Fig. 6.3A, B Peripheral osteomyelitis with articular involvement in an adult. A Sunrise view radiograph of the right knee of a 65-year-old female with medial femoral condylar infection shows peripheral osteolysis with localized joint involvement (arrow). B Semilateral pinhole scan reveals an ill-defined patchy area of increased uptake in the medial femoral condyle (arrow)

showing permeation or frank destruction of bone and periosteal new bone formation. In infants the infection in the long-bone end may extend into the adjacent joint. On occasion, articular involvement may also occur in adults when the infective focus is located in the per-iarticular bone such as the femoral or tibial condyle (Fig. 6.3A). If diagnosis is delayed or the treatment instituted is inadequate, the disease may be transformed to the subacute and chronic type, creating sequestrum, involu-crum, and cloaca. A sequestrum is denoted by bony condensation, an involucrum by sclerosis around the sequestrum, and a cloaca by an opening in the involucrum. A radiolucent rim

Involucrum Cloaca Sequestrum

Fig. 6.4A, B Chronic osteomyelitis. A AP radiograph of the right humerus of a 24-year-old male with sclerotic marrow infection shows irregular thickening of the end-osteum, cortex, periosteum, and trabecular bone (arrowheads) with bone defect (open arrow). B Pinhole scinti-graph reveals intense tracer uptake confined to the medullary cavity with mild pancortical uptake (arrowheads) with a photopenic defect (open arrow)

Fig. 6.4A, B Chronic osteomyelitis. A AP radiograph of the right humerus of a 24-year-old male with sclerotic marrow infection shows irregular thickening of the end-osteum, cortex, periosteum, and trabecular bone (arrowheads) with bone defect (open arrow). B Pinhole scinti-graph reveals intense tracer uptake confined to the medullary cavity with mild pancortical uptake (arrowheads) with a photopenic defect (open arrow)

of granulation may surround the sequestrum. When infection is protracted, sclerosing osteomyelitis may ensue. Chronic osteomyelitis is manifested as irregular thickening of the cortex, periosteum, and trabecular bone, frequently with bone defect and deformity (Fig. 6.4A).

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