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Acute Osteomyelitis Three Phase Bone Scan Osteomyelitis

Fig. 6.7A-C Three-phase 99mTc-MDP bone scintigraphy in acute osteomyelitis of the first metatarsal sesamoid. A Blood flow scintigraph of the legs in a 40-year-old female with pain and heat in the plantar aspect of the right first metatarsal head demonstrates increased vascularity in the great toe region (arrow). B Pinhole scan specifically localizes pathological uptake to the medial sesamoid of the first metatarsal head (arrow). C Tangential radiograph of the right great toe reveals lytic change in the medial sesamoid with soft-tissue swelling (arrow)

Fig. 6.7A-C Three-phase 99mTc-MDP bone scintigraphy in acute osteomyelitis of the first metatarsal sesamoid. A Blood flow scintigraph of the legs in a 40-year-old female with pain and heat in the plantar aspect of the right first metatarsal head demonstrates increased vascularity in the great toe region (arrow). B Pinhole scan specifically localizes pathological uptake to the medial sesamoid of the first metatarsal head (arrow). C Tangential radiograph of the right great toe reveals lytic change in the medial sesamoid with soft-tissue swelling (arrow)

Nuclear Angiography

Fig. 6.8A-D Nuclear angiographic assessment of the effect of antibiotic therapy of early osteomyelitis. A Plain AP radiograph of the right proximal femur in an 11-year-old boy with high fever, local pain and leukocytosis shows periosteal reaction in the lateral aspect of the proximal femoral metaphysis (arrows). B T1-weighted MRI

Fig. 6.8A-D Nuclear angiographic assessment of the effect of antibiotic therapy of early osteomyelitis. A Plain AP radiograph of the right proximal femur in an 11-year-old boy with high fever, local pain and leukocytosis shows periosteal reaction in the lateral aspect of the proximal femoral metaphysis (arrows). B T1-weighted MRI

demonstrates low signal confirming infection in the bone marrow (open arrow). C Nuclear angiograph performed 10 days after cephalosporin therapy shows no abnormal vascularity, denoting the subsidence of infection (?). D Pinhole scintigraph shows no abnormal uptake either (?)

Mri Fibula

Fig. 6.9A-C Nuclear angiographic assessment of recurrent chronic osteomyelitis. A AP radiograph of the right leg in a 28-year-old female patient with chronic osteomyelitis with clinical signs of recurrence shows nonspecific sclerosis in the midshaft of the fibula (arrow). Radiography cannot provide metabolic information. B, C Nuclear angiograph and pinhole scintigraph respectively reveal increased blood flow (arrow) and intense tracer uptake (arrow) in the midshaft of the fibula, clearly indicating reactivation of osteomyelitis

Fig. 6.9A-C Nuclear angiographic assessment of recurrent chronic osteomyelitis. A AP radiograph of the right leg in a 28-year-old female patient with chronic osteomyelitis with clinical signs of recurrence shows nonspecific sclerosis in the midshaft of the fibula (arrow). Radiography cannot provide metabolic information. B, C Nuclear angiograph and pinhole scintigraph respectively reveal increased blood flow (arrow) and intense tracer uptake (arrow) in the midshaft of the fibula, clearly indicating reactivation of osteomyelitis disease. The cortex and periosteum are thickened locally. The abscess is indicated by a lucent bone defect surrounded by an irregular sclerotic zone. Occasionally, necrotized bone or sequestrum can be seen within the defect. A dead bone is typically opaque.

The scintigraphic manifestations and the de-monstrability of subacute and chronic osteomyelitis as well as bone abscesses and osteitis depend upon the nature of bone pathology and tive change in the cortex. Pinhole scintigraphy the scintigraphic method applied. Understan- can clearly resolve the apparently homogene-dably, ordinary bone scintigraphy provides less ous "hot" area shown on an ordinary scinti-information than pinhole scintigraphy graph into two or more different components: (Fig. 6.10B). This rule is particularly applicable the main marrow space pathology and associa-to the assessment of the metaphyseal localiza- ted cortical change (Fig. 6.10C). In general,

Images Osteomyelitis Finger

subacute or chronic osteomyelitis is indicated by a bizarre mixture of increased and decreased uptake representing, respectively, sclerotic and dead bone. The abscess or sequestrum larger in size than a finger tip can be shown as a "cold" defect surrounded by intense uptake; the demarcation is usually sharp. The smaller abscesses or involucra are indicated by a spotty "hot" area scattered within a large lesional area. Sequestra are not visualized because they are devitalized and unable to concentrate tracer. By the fusion of pinhole scan and radiography images after size-equalization, the tracer uptake and radiographic density can be correlated. Although our experience was limited it appeared that the area with increased uptake roughly corresponds to radiolucent or less sclerotic areas of chronic osteomyelitis and vice versa (Fig. 6.11). A possible implication of this observation is that the persistently active inflammatory foci in long-standing osteomyelitis likely remain in the radiographically lucent or less sclerotic area with increased tracer uptake than in the markedly sclerotic areas with little or no tracer uptake. Nuclear angiography can provide valuable objective information on the vascularity that increases in an active infective focus (Yang et al. 1988) (Fig. 6.9B).

Fig. 6.10A-C Radiographic and scintigraphic alterations in chronic osteomyelitis with involucra (abscesses), sclerosis, and cortical thickening. A Anteroposterior radiograph of the left proximal femur in a 31-year-old man with intractable osteomyelitis shows irregular osseous and cortical thickening, lucent involucra (arrowheads), and deformity. B Ordinary spot scintigraph reveals homogeneous tracer uptake without textural detail (arrowheads). C Anterior pinhole scan shows patchy areas of intense tracer uptake, representing the involucra, osteo-sclerosis, and cortical thickening

Intense Tracer

Fig. 6.11A, B Superimposition of a pinhole scintigraph on a radiograph in chronic osteomyelitis. A Anterior pinhole scintigraph of chronic osteomyelitis in the left distal femur shows mottled and patchy areas of increased tracer uptake. B Superimposition of transcribed scintigraphic alterations shown in A on the radiograph after image size equalization by photographic enlargement reveals more intense tracer uptake in radiographically less dense or lucent area, denoting the foci with residual inflammation (dotted areas). In contrast, the radiodense areas do not concentrate tracer detectably

Fig. 6.11A, B Superimposition of a pinhole scintigraph on a radiograph in chronic osteomyelitis. A Anterior pinhole scintigraph of chronic osteomyelitis in the left distal femur shows mottled and patchy areas of increased tracer uptake. B Superimposition of transcribed scintigraphic alterations shown in A on the radiograph after image size equalization by photographic enlargement reveals more intense tracer uptake in radiographically less dense or lucent area, denoting the foci with residual inflammation (dotted areas). In contrast, the radiodense areas do not concentrate tracer detectably

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