Skeletal Radiol (2011) 40:963975

DOI 10.1007/s00256-010-0975-4

REVIEW ARTICLE

Bony sequestrum: a radiologic review

Flicie Jennin & Valrie Bousson & Caroline Parlier &
Nabil Jomaah & Vanessa Khanine & Jean-Denis Laredo

Received: 12 September 2009 / Revised: 21 April 2010 / Accepted: 14 May 2010 / Published online: 23 June 2010
# ISS 2010

Abstract According to a pathological definition, a bony

sequestrum is defined as a piece of devitalized bone that
has been separated from the surrounding bone during the
process of necrosis. However, the radiological definition
of a sequestrum is different and refers to an image of
calcification visible within a lucent lesion, completely
separated from the surrounding bone, without referring to
the vascular status and histological nature of the calcified
tissue. The term button sequestrum has been used in
calvarial lesions. The prototype conditions that may
present with a bony sequestrum are osteomyelitis and
skeletal tuberculosis. Other conditions such as radiation
necrosis, eosinophilic granuloma, metastatic carcinoma,
primary lymphoma of bone, aggressive fibrous tumors
may also manifest as osteolytic lesions containing a
sequestrum. In addition, some primary bone tumors
produce a matrix that may mineralize and sometimes
simulate a bone sequestrum. These include osteoid
tumors (osteoid osteoma, osteoblastoma), cartilaginous
tumors (chondroma and chondroblastoma), lipomatous
tumors (lipoma), and benign fibrous tumors (fibromyxoma, myxoma, and desmoplastic fibroma). Therefore,
various conditions may present at imaging as a small
area of osteolysis containing central calcifications. However, a careful analysis of the sequestrum as well as the
associated clinical and radiological findings often enables
to point toward a limited number of conditions.

F. Jennin (*) : V. Bousson : C. Parlier : N. Jomaah : V. Khanine :

J.-D. Laredo
Department of Radiology, Lariboisire Hospital,
2 rue Ambroise Par,
75475 Paris, Cedex 10, France
e-mail: fejennin@yahoo.fr

Keywords Sequestrum . Osteolysis . Calcified tissue . CT .

MR. Osteomyelitis . Skeletal tuberculosis . Primary bone
lymphoma . Skeletal metastases . Bone tumor

Introduction
Several different definitions are used in the literature for a
bony sequestrum. According to a pathological definition, a
bony sequestrum is defined as a piece of devitalized bone
that has become separated from the surrounding bone
during the process of necrosis [1]. According to this
definition, bone infection is the prototype condition
presenting with a bony sequestrum.
The term button sequestrum was coined by Wells
and refers to an osteolytic lesion with a central nidus of
intact bone which was encountered in calvarial involvement of eosinophilic granuloma [2]. Further reports
showed that the image of button sequestrum could also
be seen in a large panel of conditions involving the skull,
including tuberculous osteitis [3, 4], staphylococcal
osteitis [4], metastatic carcinoma [4, 5], meningioma [4],
osteoblastoma [6], hemangioma, dermoid and epidermoid
cysts [4, 5], fibrous dysplasia, radiation necrosis [4, 5, 7],
and a healing surgical defect [5].
On radiographic and computed tomography (CT)
images, a sequestrum manifests as a piece of calcified
tissue within a lucent lesion without referring to the
vascular status and histological nature of this calcified
tissue. Even in cases where the sequestrum occupies
most of the osteolytic area, a lucent rim completely
separates the sequestrum from the surrounding bone. CT
with multiplanar reformations has made the recognition
of a sequestrum much easier. However, it is not possible
at radiography and CT to differentiate sequestra consist-

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ing of either necrotic bone, residual viable bone, or foci

of matrix calcification or ossification. Magnetic resonance
imaging (MRI) with non-enhanced and gadolinium-enhanced
sequences has the potential to differentiate a true avascular
sequestrum surrounded by necrotic tissue from a piece of
residual vascularized normal bone surrounded by a
vascularized lesional tissue. However, small calcifications
may be overlooked at MRI, and MRI should be optimally
used in conjunction with CT.
In this article, we will refer to a sequestrum as a single piece
of bone contained in an area of osteolysis and separated from
the surrounding bone, whatever the vascular status of the
piece of bone. We will review the various conditions which
may present with an image of sequestrum on radiographs, CT,
or MR images. The prototype conditions which may present
with an image of bony sequestrum are osteomyelitis and bone
tuberculosis. Other conditions which may manifest as
osteolytic lesions containing a sequestrum include radiation
necrosis, eosinophilic granuloma, metastatic carcinoma,
primary lymphoma of bone, and aggressive fibrous tumors.
In addition, we will briefly mention the primary bone tumors
that produce a matrix that may mineralize such as
osteoid tumors (osteoid osteoma, osteoblastoma), cartilaginous tumors (chondroma and chondroblastoma), lipomatous
tumors (lipoma), and benign fibrous tumors (fibromyxoma,
myxoma and desmoplastic fibroma) and may therefore
simulate a bony sequestrum.

Conditions possibly associated with an image

of sequestrum
Osteomyelitis
The most common type of osteomyelitis involves the
metaphysis of tubular long bones in children, with possible
epiphyseal extension in infants. In the mature skeleton,
hematogenous osteomyelitis is more common in the spine,
pelvis, and small bones than in the tubular bones [8].
Brodies abscess, a sharply delineated focus of chronic
bone infection, often contains a sequestrum.
The radiologic appearance of osteomyelitis is characterized by an area of irregular and ill-defined bone
destruction with sinuous margins, and reactive surrounding sclerosis of variable extent and degree. This sinuous
shape is very uncommon in bone tumors and therefore
suggestive of bone infection. Sometimes there are several
confluent areas of bone destruction. Lucent areas may
connect to the growth plate or to the surface of the bone
through a tortuous channel.
The search for sequestra is a common and important
diagnostic challenge in chronic osteomyelitis. The presence of a sequestrum may lead to a decision of surgery

Skeletal Radiol (2011) 40:963975

to remove the necrotic tissue. Imaging studies that may

be useful in characterizing the sequestrum include radiographs, CT, MR with contrast studies, sinography, and
CT sinography. In tubular bone osteomyelitis, osseous
necrosis is commonly situated in the cancellous bone
(Fig. 1). The sequestrum is frequently sharply marginated
as it rests in a space surrounded by granulation or
necrotic tissue. Multiple sequestra are frequently seen.
They vary in size from minute fragments to long necrotic
segments. The increased density of the sequestrum
relative to the surrounding bone on radiographs and CT
is a consequence of its absence of blood supply. As a
consequence of this devascularization, the sequestrum
does not participate in the reactive hyperemia and
therefore does not exhibit the osteopenia of the adjacent
living bone.
Non-enhanced and gadolinium-enhanced MR sequences are needed to fully characterize a sequestrum in a
chronic osteomyelitis. The MR appearance is very
suggestive of a chronic bone abscess containing a
sequestrum when a central area of low signal intensity
which does not enhance after contrast administration is
surrounded by avascular necrotic tissue. At an earlier
stage, however, the sequestrum may be surrounded by
enhancing granulation tissue, resulting in a less characteristic appearance. In any case, the comparison of the
CT and MR findings is useful to fully characterize the
sequestrum. In cases with a draining sinus, sinography
that consists of the opacification of the sinus tract
through the cutaneous fistula and CT-sinography may
demonstrate the connection between the bone abscess
containing the sequestrum and the draining sinus. With
time, the sequestrum may extrude through cortical
breaks, extending within the adjacent soft tissues, where
it is sometimes discharged through draining sinuses.
Sequestration of a piece of cortical bone is less
frequent and usually takes the appearance of a Brodies
abscess (Fig. 2). In childhood, bone necrosis is facilitated
by the deprivation of blood supply to the inner portion of
the cortex, which is caused by thrombosis of the
metaphyseal vessels and interruption of the periosteal
vessels. Cortical necrosis and sequestration can subsequently appear. In adults, extensive sequestration of the
cortical bone is not a common feature, due to the intimacy
of the periosteum and cortex, which ensures adequate
cortical bone blood supply in most patients. Bone
sequestration is much less common in flat bones.
Sequestration of a piece of subchondral bone is not
uncommon in septic arthritis of the sacro-iliac joint
(Fig. 3) and is a differential criterion from inflammatory
sacroiliitis. In peripheral arthritis, areas of necrosis may be
present on both sides of the affected joint with a kissing
sequestra appearance [8].

Skeletal Radiol (2011) 40:963975

Fig. 1 Brodies abscess of the
left femur in an 8-year-old
boy. Sagittal (a) and transverse
(b) computed tomography (CT)
images showing oval-shaped
osteolysis with irregular margins, containing a dense sequestrum (arrow). The other
lytic area corresponds to the
medullary cavity (arrowhead).
The lesion exhibits isosignal
intensity on transverse T1weighted MR (c) and high
signal intensity on T2-weighted
MR (d) images. Also shown are
dynamic-gadolinium-enhanced
MR sequences (e and f) showing a delayed lesion enhancement (yellow curve) in
comparison to the next artery
(red curve) with a central area
of low signal intensity that does
not enhance after contrast administration and corresponds to
the sequestrum

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Slow-growing microorganisms such as spirochetes and

fungal infection may also contain a bone sequestrum in the
same way [8].
Skeletal tuberculosis
Skeletal tuberculosis deserves a special mention since bone
sequestration is a relatively uncommon but well-recognized
finding of this disease [9].
The spine is the most frequent location of skeletal
tuberculosis. Most typical presentations include vertebral
body destruction and collapse, disk-space narrowing, anterior
scalloping of the vertebral bodies, and large paraspinal softtissue masses representing abscess formation [7]. In the more

chronic stages, CT typically shows extensive osseous

destruction and sequestrum formation [7]. For some authors,
the presence of a sequestrum is suggestive of bone
tuberculosis [7]. The sequestrum is located in an area of
vertebral body destruction or in abscesses. A particular form
of spinal tuberculosis is centrosomatic tuberculosis, which is
characterized by round-shaped osteolysis, peripheral bone
sclerosis, and central sequestrum [10]. There is typically a
single lesion with a sequestrum.
Extraspinal bone tuberculosis in the absence of associated
tuberculous arthritis is relatively rare. When it does occur,
however, the femur, tibia, and small bones of the hands and
feet are most commonly affected. Typically, the lesion
involves the metaphysis, with radiographic features which

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Skeletal Radiol (2011) 40:963975

Fig. 2 Intra-cortical Brodies

abscess of the right tibia in a
21-year-old man. Coronal
(a) and transverse (b) images
showing the bone abscess within
the posterior cortex containing a
central and dense calcification
(arrow). The appearance mimics
an osteoid osteoma

include osteopenia and poorly defined lytic lesions with

minimal surrounding sclerosis [11]. The presence of a
sequestrum is uncommon in these lesions.
Cystic tuberculosis is an unusual pattern of bone
tuberculosis that occurs more commonly in children than
in adults, especially in Africans. It is characterized by

multiple small, well-defined oval lytic lesions of variable

size that usually lack sclerotic margins. In children, the
metaphyses of the long bones tend to be affected, whereas
in adults, the axial skeleton (vertebrae, skull, shoulder, and
pelvis) is involved [11]. We illustrate a previously reported
case of biopsy-proven disseminated vertebral tuberculosis
(cystic tuberculosis), in a 26-year-old man from India [12].
Vertebral lesions were disseminated in the lumbar spine and
sacrum and appeared as multiple round-shape areas of
osteolysis containing a central large sequestrum and
producing the button sequestrum appearance in the skull
(Fig. 4).
Radiation necrosis
A button sequestrum appearance of the calvaria related to
radiation necrosis was reported in the 1950s in intracranial
tumors managed with radiotherapy [13]. However, to our
knowledge, a button sequestrum of the calvaria has not
been reported since the report of Rosen and Nadel in 1969
[4] and was possibly related to the technique of radiation
used at that time.
Langerhans cell histiocytosis

Fig. 3 Septic sacroiliitis in an 80-year-old woman. Anteroposterior

radiograph of the pelvis showing destruction of the right sacro-iliac
joint. CT coronal image showing destruction of the subchondral bone
predominating on the iliac margin with a linear intraarticular
sequestrum in the upper part of the joint (arrow)

Skeletal involvement in Langerhans cell histiocytosis

(LCH) manifests in a variety of ways, the most common
being the eosinophilic granuloma, a localized and often
solitary bone lesion that occurs predominantly in the
pediatric age group.
Although solitary LCH can arise in any bone, more than
half of the cases occur in the skull, pelvis, mandible, or ribs.
Long and flat bones are equally affected in children,
whereas in patients older than 20 years, most LCH lesions
arise in flat bones, predominantly the ribs. When long

Skeletal Radiol (2011) 40:963975

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and radiodense fragment of intact bone, referred to as button

sequestrum [2, 15] (Fig. 5). It has been suggested that the
button sequestrum encountered in eosinophilic granuloma is
not the product of matrix mineralization but rather a residual
island of intact bone [5].
Whereas presence of an image of button sequestrum is
a well-known possibility in LCH of the skull, only a few
cases of LCH with a sequestrum have been reported
outside the skull to our knowledge. Two cases involving
the femur and exhibiting an image of sequestrum are
mentioned without further description in a cases series
[16]. Another reported case involving the proximal femur
presented as a lucent lesion with a thin lateral sclerotic
margin located in the medial cortex of the subtrochanteric
region. A CT scan image showed a small internal density
in the lucent lesion, suggestive of a sequestrum [17].
Tordeur et al. reported a case of eosinophilic granuloma
involving the ilium that contained several faint sequestra
in a lytic lesion with sharply defined borders and cortical
endosteal scalloping [18]. We presently illustrate two
cases of biopsy-proven eosinophilic granuloma occurring
both in young male adults and appearing as osteolytic
lesions containing a sequestrum. The first case appears as
a well-defined osteolytic lesion of the ischium containing
a poorly defined central sequestrum (Fig. 6). The other
case manifests as an osteolytic lesion of the left pubic
bone containing a central minute sequestrum (Fig. 7).
Metastatic carcinoma

Fig. 4 Vertebral tuberculosis in a 26-year-old man from India. CT

transverse images through L2 vertebral body, with bone window (a)
and soft tissue window (b) settings, showing multiple small round
osteolytic lesions with well-defined non-sclerotic margins, containing
a single central large sequestrum

bones are affected, particularly the femur and the humerus,

diaphyseal and metaphyseal locations are much more
frequent than epiphyseal locations [5, 14].
In long bones, LCH initially presents as a small area of
medullary destruction. This may either regress to a welldefined oval- or round-shaped geographic pattern with
sclerotic margins or progress to cause endosteal scalloping,
cortical erosion, a thick single-layered or less frequently
laminated periosteal reaction, and soft-tissue swelling.
Chronic, late-stage lesions and lesions in flat-bones (e.g.,
skull, pelvis, and scapula) are better defined [5]. Reactive
sclerosis around an osteolytic lesion may represent early
spontaneous healing and suggests a favorable prognosis [5].
In the skull, lesions develop in the diploic space and are
round or oval-shaped with well-defined beveled margins,
characteristically described as punched-out lytic lesions. Lytic
lesions of the cranial vault sometimes contain a unique central

Only a few cases of bone metastases with an image of bone

sequestrum have been reported to our knowledge. Rosen

Fig. 5 Eosinophilic granuloma of the skull of a 26-year-old woman.

Lateral radiograph showing a "button" sequestrum. The radiolucent
defect of the right parietal bone is sharply delineated and contains a
central sequestrum

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Fig. 6 Eosinophilic granuloma of the right ischium in a 20-year-old

man. Transverse CT image showing a well-defined osteolytic lesion
containing a faint calcification (arrow)

and Nadel reported a case involving the skull [4].

Sartoris et al. reported a case of vertebral metastasis from
a malignant melanoma presenting as an osteolytic eccentric lesion with irregular and ill-defined margins without
reactive surrounding sclerosis involving the posterior
aspect of a vertebral body and containing multiple images
of bone sequestrum [19]. A case of vertebral metastasis
from a renal cell carcinoma involving the posterior part of
a vertebral body and presenting as an ill-defined osteolytic
area containing a minute piece of bone is illustrated in
Resnicks textbook [20]. Figure 8 illustrates a biopsyproven vertebral metastasis from an endometrial carcinoma in a 69-year-old woman appearing as an irregular and
ill-defined osteolytic lesion of L4 containing multiple
eccentric sequestra of different sizes and densities.
Figure 9 illustrates another case of biopsy-proven multiple
vertebral metastases from a breast adenocarcinoma in a
22-year-old woman discovered on a CT examination
performed for a compression fracture of L1. It reveals
multiple round-shaped areas of osteolysis in which most
lesions contain a single central bone sequestrum. We
found no such case of multiple vertebral metastases with
bony sequestrum in the literature.
Primary lymphoma of bone
Primary lymphoma of bone is a rare malignant condition
that accounts for less than 5% of all primary bone tumors

Fig. 7 Eosinophilic granuloma of the left pubic bone in a 25-year-old

man. Transverse CT image with bone window (a) and soft tissue
window (b) settings showing an osteolytic lesion with endostal
scalloping and cortical destruction containing a central minute
calcification (arrow)

[21]. Primary lymphoma of bone involves children and

adults of all ages with a peak prevalence among patients in
the sixth or seventh decades of life [22]. The femur,
especially the metadiaphyseal region, is affected in 25% of
cases. Other sites include the pelvis, the humerus, especially the proximal extremity, and the tibia [22]. The most
common radiographic appearances are a purely lytic (70%)
or a mixed, lytic and sclerotic, (28%) patterns. A purely
sclerotic lesion is rare (2%) [21]. In the series of Mulligan
et al., most cases exhibited a permeative or moth-eaten lytic
pattern (74%) associated with an aggressive periostal
reaction (47%) consisting of either a solid single layer
(32%) or multiple interrupted layers (52%) of periosteal
bone [21]. Extensive bone involvement, cortical destruction, and a broad zone of transition were other typical
findings. A soft-tissue mass was present in 48% of the cases
[21].
An image of sequestrum was present in 11% of the cases
in the series of Mulligan and Kransdorf [23] and 16% in the
series of Mulligan et al. [21]. These authors obtained no

Skeletal Radiol (2011) 40:963975

Fig. 8 Vertebral metastasis from an endometrial carcinoma involving

the L4 vertebral body in a 69-year-old woman. Transverse CT image
with bone window (a) and soft-tissue window (b) settings showing a
poorly defined osteolytic lesion of the left part of the vertebral body
with focal cortical destruction, containing multiple eccentric bony
sequestra
Fig. 9 Multiple lumbar
metastases from a breast adenocarcinoma in a 22-year-old
woman. Sagittal (a) and axial
(b) CT reformations showing
multiple poorly defined and
round-shaped osteolytic lesions
containing a round central
sequestrum separated from the
surrounding bone by a lucent
rim. Sagittal T1-weighted (c),
gadolinium-enhanced fatsaturated T1-weighted (d), and
T2-weighted (e) MR images
showing multiple round
enhancing lesions except for the
central sequestrum which does
not enhance

969

histologic proof of the vascular status of the piece of bone

since primary lymphoma of bone was treated non-surgically
but suggested this image corresponded to a true sequestrum
based on the radiologic appearance [23].
Among the 28 cases reported by Mulligan and Kransdorf, 15 (54%) were located in the long bones (femur
seven, tibia six, humerus two) and ten were in the axial
skeleton (ilium four, calvaria three, sternum two, and pubis
one). Unusual sites were affected in the remaining three
cases (11%) (scapula, calcaneus, and third metatarsal) [23].
Multiple sequestra (two to five in each case) were seen in
17 cases. Sequestrum size varied from 2 to 45 mm
(average, 12 mm) [23]. They were found mainly in areas
of permeative (16 cases) or geographic (ten cases)
destruction and had the same density as the rest of the
involved bone [23]. Figure 10 illustrates a case of biopsyproven primary lymphoma involving the ala of the right
ilium, showing an ill-defined osteolysis with cortical
destruction and containing several sequestra.

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Primary bone tumors producing a matrix that may

mineralize and simulate a bony sequestrum
In almost all primary bone tumors producing a protein
matrix, this matrix may undergo focal matrix calcification.
However, only in a few cases, the radiologic appearance of
a bony sequestrum as defined above is present, namely a
small grossly circumscribed osteolytic lesion containing a
single calcification completely separated from the surrounding bone. In the present section, we will briefly review the
primary bone tumors that are more prone to mimic a
radiologic image of bony sequestrum on transverse CT or
MR images.
Fig. 10 Primary lymphoma of the right ilium. Transverse CT image
showing a mixed lesion with bone sclerosis in the posterior ilium and
a poorly defined osteolytic area anteriorly, destroying the subchondral
bone of the sacro-iliac joint and containing several irregular bony
sequestra (case kindly provided by Nabil Jomaah MD)

Aggressive fibrous tumors

Occasional cases of malignant fibrous tumors containing a
bone sequestrum have been reported. Helms et al. first
mentioned without further description two cases of malignant fibrosarcoma containing an image of bony sequestrum
[24]. An ill-defined image of sequestrum is visible in a
reported case of malignant fibrohistiocytoma involving the
carpal bones [24]. Since these tumors do not produce
mineralized tumor matrix, the bone fragments separated
from the involved segment have been called sequestra.
However, the vascular status and histology of the calcified
tissue composing the sequestrum associated with these
tumors has not been studied. In fact, any aggressive
primary neoplasm of bone can eventually lead to the
formation of a bone sequestrum because of the rapid
destruction of bone and entrapment of partially destroyed
bone in the tumoral mass [23].

Fig. 11 Osteoid osteoma

involving the posterior cortex
of the left femoral neck of an
11-year-old girl. The nidus has a
round shape in the transverse
plane (a) and is slightly
elongated along the main bone
axis in the coronal plane at CT
(b). There is a central calcification with a peripheral lucent
rim (arrow)

Osteoid tumors
Osteoid osteoma and osteoblastoma are two closely related
benign bone tumors producing an osteoid matrix consisting of
a well-vascularized connective tissue stroma in which there is
active production of osteoid and primitive woven bone [20].
Both tumors are observed most frequently in children and
young adults. With maturation, there is a progressive
mineralization of the osteoid which is converted to trabeculae of coarse woven bone that may fuse to form an
anastomosing network. The degree of calcification is
variable, some lesions being extensively calcified. Radiographically, osteoid osteomas and small osteoblastomas often
exhibit a central calcification mimicking a sequestrum.
Osteoid osteomas are small tumors (<20 mm) often
located in the tubular bones, especially those in the lower
extremities, with 50 to 60% of the cases occurring in the
femur or tibia. Their classic radiological appearance is a
round or oval lytic nidus with well-defined and regular
margins, surrounded by a zone of uniform bone sclerosis.
In 80% of the cases, the nidus contains variable amounts of
calcification. Even in the case of a heavily calcified nidus, a
lucent rim completely delineates the central calcification
from the surrounding reactive sclerosis (Figs. 11 and 12).

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Fig. 12 Osteoid osteoma
involving the anterior cortex
of the right tibia of a 10-year-old
girl. The nidus is slightly
elongated along the main bone
axis in the sagittal plane
(a) at CT. The lesion exhibits
isosignal intensity on transverse
T1-weighted MR (b) and high
signal intensity on T2-weighted
MR (c) images (arrow). On the
contrary to Brodies abscess
(Fig. 1), dynamic-gadoliniumenhanced MR sequences
(d and e) showing a early lesion
enhancement (red curve) in
comparison to the next artery
(yellow curve)

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Osteoblastomas are larger (>20 mm) and much more

variable in their radiological appearance than osteoid
osteomas. Sixty percent originate in the spine, usually from
the neural arch [6]. Seventy-two percent of the osteoblastomas localized in the spine exhibit matrix ossification [6].
Small osteoblastomas resemble osteoid osteomas and often
contain a central calcification, similar to osteoid osteomas.
Larger lesions demonstrate cortical expansion with a thin
cortical shell and may contain multiple foci of calcifications
with a radiological appearance different from a bony
sequestrum [6].
Osteoblastomas localized in the skull have a particular
appearance. They look like radiolucent coins with amorphous matrix ossification in the center surrounded by a
smooth sclerotic zone [6] and may therefore appear as a

button sequestrum, although in the true button sequestrum

of the skull, these opacities are remnants of preexisting
bone.
Cartilaginous tumors
Cartilaginous tumors often demonstrate multiple minute
calcifications. Only small chondromas are likely to appear
as a lytic lesion with a single central calcification. These
calcifications may be due to the deposition of calcified
material within the cartilaginous matrix or to a process of
enchondral ossification at the periphery of the cartilaginous
lobules. They typically appear as coarse granular calcifications or may form arc and rings with the typical chickenwire appearance [25]. These appearances are easily

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differentiated from a bony sequestrum in most cases.

Occasionally, however, chondroblastomas (Fig. 13) and
less likely chondromas (Fig. 14) may present as a round
lytic lesion containing minute calcifications, but this
appearance is usually not confused with a sequestrum
[26]. Tumor location in the epiphysis of a long bone is
another finding suggestive of a chondroblastoma. Another
finding characteristic of cartilaginous tumors is their
lobulated pattern. Chondrosarcomas are usually larger
lesions that do not appear with an image of sequestration
as defined above.
Lipomatous tumors
Intraosseous lipoma is a benign bone tumor seen at any age
with a peak frequency in the fourth decade [27]. Seventyone percent of the cases involve the lower limb especially
the calcaneum the subtrochanteric region of the femur, the
proximal tibial metaphysis, the distal femoral metaphysis
and the proximal and distal fibular metaphyses. The
radiologic appearance is a geographic area of osteolysis
with well-defined margins and a partial or complete
marginal sclerosis in 45% of the cases [27]. Computed
tomography or MRI demonstrates the characteristic fat
content. A cystic component, usually in central location, is
present in 67 % of the cases and is even more frequent in
the calcaneum [27].
An intralesional calcification or ossification, usually in a
central location, was present in 42% of the cases of the
series of Campbell et al. [27]. This calcification may mimic
to some extent a bony sequestrum on conventional radiographs but lesion width usually exceeds 2 cm [20]. In
addition, findings at CT or MRI are almost pathognomonic
of a fat-containing lesion. In most of the cases which
exhibit a central calcification or ossification, CT and MR
images show that the calcification consists of a bony ridge

Fig. 13 Chondroblastoma of the proximal tibial epiphysis of a 14year-old girl. The lytic lesion has a round shape and contains a minute
eccentric calcification (arrow) on a coronal CT reformation

Fig. 14 Chondroma of the right hip of a 63-year-old woman. Axial

(a) and coronal (b) CT reformations of the right hip show an osteolytic
lesion with lobulated pattern containing chondroid calcifications. One
of these calcifications mimics a bony sequestrum (arrow)

surrounding a central cystic component. Cyst formation,

calcification, and reactive ossification occurring in intraosseous lipomas have been attributed to fat necrosis
secondary to infarction [28].
Benign fibrous tumors
Fibromyxomas and myxomas of bone are rare benign
tumors [29]. Most patients are in the second or third
decades of life. The most common site of origin is the jaw
bones (maxilla or mandible), where the tumor is often
known as ontogenic myxoma. Fibromyxoma are rarely
encountered in extragnathic bones such as the iliac crest,
tibia, ulna, femur, ribs, humerus, and toes [29]. The long
tubular bones seem to be chiefly affected by this lesion
[29]. The radiological findings of fibromyxomas of bone
are nonspecific. They may present with bone destruction
and cortical expansion and less commonly with an
aggressive osteolysis or with signs of reactive sclerosis.
Some lesions present multiple foci of calcification and
ossification due to tumoral matrix mineralization which can
usually be easily differentiated from a single bony
sequestrum [29, 30].
Desmoplastic fibroma is a rare benign primary bone
tumor, histologically similar to the more frequent soft-

Skeletal Radiol (2011) 40:963975

tissue desmoid tumor [31]. This tumor involves preferentially the meta-diaphyseal region of long bones, the
mandible, and the pelvic bones [32]. A geographic pattern
of bone destruction with a narrow zone of transition, nonsclerotic margins (96%), internal pseudo-trabeculation
(91%), and cortical thinning is frequent (89%) [32].
Helms et al. reported two cases of desmoplastic fibroma
with a single, central and dense ossification simulating a
sequestrum in the diaphysis of the ulna and radius in
middle-age adults [24].

Diagnostic approach
Diagnosis of the various conditions associated with an
image of bone sequestrum is based on a combination of
multiple clinical, biological, and radiological criteria. Most
distinctive criteria are listed in Table 1. No single criterion
is diagnostic in isolation. The patients age, the lesion size,
and number of radiological lesions are among the most
important criteria.
Many of the conditions which may produce a single
radiographic image of bone sequestrum are encountered
in the second or third decades of life (Table 1). Bone
infection, osteoid osteoma, chondroblastoma, eosinophilic
granuloma, and chondroma are the most frequent lesions
in this age range. Night pain is suggestive of an
inflammatory condition such as bone infection, osteoid
osteoma, osteoblastoma, chondroblastoma, eosinophilic
granuloma, and malignant primary and secondary tumors.
Bone infection should be suspected in case of fever,
history of infection, recurrent pain episodes, and biological inflammation.
A single lesion of less than 2 cm in diameter with a
central calcification and a lucent rim in the second or third
decades of life is suggestive of an osteoid osteoma.
However, other conditions such as a Brodie abscess or a
small chondroblastoma may closely mimic an osteoid
osteoma. Some subtle radiographic findings may be
helpful to differentiate an osteoid osteoma from these
conditions. The nidus of an osteoid osteoma is grossly
round or slightly elongated along the main bone axis. Its
margins are regular and smooth. It contains a central dense
calcification of variable size. Small chondroblastomas and
chondromas usually have a round shape but with lobulated
contours suggestive of their cartilaginous lobular architecture. They may contain faint, spotty, usually multiple
calcifications. In Brodie abscess and more globally in
bone infection, the central lytic area is typically not round
but rather elongated with a sinusal shape and irregular
margins and contain one or several sequestra. In cortical
Brodies abscesses, the sequestrum is a piece of cortical
bone and typically has an elongated shape.

973

In the case of a single lesion larger than 2 cm with a

central calcification in a patient in the second or third
decades of life, a large panel of conditions including
bone infection, bone tuberculosis, eosinophilic granuloma, chondroblastoma, osteoblastoma, chondroma, benign
fibrous lesions, and lymphoma should be considered. In
an older age group, eosinophilic granuloma, chondroblastoma, and osteoblastoma are less likely, and lymphoma, fibrosarcoma, and a bone metastasis should be
included in the differential diagnosis. Ill-defined margins
of the osteolytic area at radiographic or CT evaluation
are suggestive of an aggressive process such as bone
infection, bone tuberculosis, or a malignant tumor mainly
lymphoma, fibrosarcoma or bone metastasis.
The quest for sequestra in chronic osteomyelitis may be
a diagnostic challenge. Therefore, in case of cutaneous
fistula, contrast medium may be injected within the sinus
track (sinography and CT sinography) to prove the presence
of a sequestrum when the contrast medium reaches and
surrounds the piece of bone.
MRI contributes to the differential diagnosis of an
osteolytic lesion containing a sequestrum. It is sometimes
easier at MRI than at CT to recognize a small amount of
intralesional fat indicative of a lipomatous process. On
T2-weighted images, very high, fluid-like signal intensity
of the central area is suggestive of an abscess. Cartilaginous lesions will exhibit lobular high signal intensity on
these sequences while fibrous and bone-forming lesions
may show from low to high signal intensity depending
on the predominant tumor matrix and amount of
mineralization. Edema of the surrounding bone is another
important MR finding that is suggestive of an inflammatory lesion such as bone infection, benign primary
tumors such as osteoid osteomas, osteoblastomas or
chondroblastomas, eosinophilic granuloma and some
high-grade malignancies. Absence of surrounding edema
makes a fibrous lesion or chondroma more likely.
Gadolinium-enhanced MR sequences have theoretically the potential to differentiate a true avascular sequestrum as seen in infections from a living vascularized
piece of remnant bone. This is true when the sequestrum
or sequestrum-like piece of calcified tissue is not too
small. However, small and sclerotic ossifications such as
those seen in osteoid osteomas commonly demonstrate
no gadolinium enhancement. Dynamic gadoliniumenhanced MR sequences are a useful means to
differentiate osteoid osteomas that show early nidus
enhancement at the arterial phase from Brodie abscesses
which exhibit delayed enhancement (Figs. 1, 2, 3, 4, 5, 6,
7, 8, 9, 10, 11 and 12) [33]. Other highly vascularized
lesions such as osteoblastomas and chondroblastomas may
also demonstrate such an early enhancement but this
remains to be established.

Usually 1030
years
Variable pain

Usually 1030
years
Night pain

Osteoid
osteoma

Marked

Delayed

Single or
multiple, irregular,
dense, sometimes
connected to the
surrounding bone

Marked

Delayed (parenchymatous
phase)

Number of
sequestrum

Peripheral
edema
(MRI)
Lesion
enhancement
(gadoliniumenhanced
MRI)

Single or multiple,
irregular, dense

Ill-defined

Ill-defined,
irregular

Lesion margins

Irregular or round

Cancellous bone or
medullary cavity

Variable

Yes

Delayed

Marked

Single or multiple,
elongated
(cortical
sequestrum)

Usually elongated
along the bone
axis
Well-defined,
irregular

Cortical bone

Usually 24 cm

Yes

Early (arterial
phase)

Marked

Single, dense,
variable
shape

Round or sharply
elongated along
the bone axis
Well-defined,
regular

Cortical >
cancellous
bone

<2 cm

None or mild

Immunosuppression History of infection

(inconstant)

Variable pain

Variable

Irregular

Usually large
(>3 cm)
Cancellous bone
or medullary
cavity

History of
infection
(inconstant)
Yes

Usually 1030
years
Variable pain

Tuberculous osteitis Intracortical

abscess

Lesion shape

Lesion center
location

Biology
inflammation
Lesion size

Patient historis

Clinical findings

Age

Osteomyelitis

Early

Marked

Marked

Usually multiple
(spotty
calcification)

Well-defined,
regular

Well-defined

Usually multiple
(spotty
calcification)

Grossly round
or ovoid

Epiphysis of long
bones

Usually 25 cm

None or mild

Night pain

Usually 1030 years

Chondroblastoma

Grossly round
or ovoid

Cancellous bone or
medullary cavity

None or mild
inflammation
Variable >2 cm

Night pain

Usually 1030 years

Osteoblastoma

Delayed

Marked

Welldefined,
regular or
irregular
Usually
single,
faint

Usually
24 cm
Cancellous
bone
or medullary
cavity
Grossly round
or ovoid

None

Usually 1030
years
Variable

Eosinophilic
granuloma

Metastase

Yes

Permanent

Yes

Primary cancer
constant

Permanent

Variable adult Usually >50

Fibrosarcoma

Ill-defined

Ill-defined

Heterogenous
early and
delayed

Single or
Usually
Usually
multiple
multiple,
multiple,
sometimes
sometimes
connected
connected
to the
to the
surrounding
surrounding
bone
bone
Mild
Mild
Variable

Ill-defined

Usually >5
Usually
Variable
cm
>5 cm
Cancellous
Cancellous
Cancellous bone
bone or
bone or
or medullary
medullary
medullary
cavity
cavity
cavity
Grossly round Grossly round Grossly round
or ovoid
or ovoid
or ovoid

Yes

Permanent

Variable adult

Lymphoma

Table 1 Table showing conditions which may produce a single radiographic image of bone sequestrum and their main clinical and imaging features/characteristics

974
Skeletal Radiol (2011) 40:963975

Skeletal Radiol (2011) 40:963975

The finding of multiple bone lesions containing an

image of sequestrum is very uncommon and should point
towards bone metastases and bone tuberculosis.

975

15.
16.

Conclusions
In conclusion, a bone sequestrum manifests on radiological
images as a piece of calcified tissue within a lucent lesion
without referring to the vascular status and histological
nature of this calcified tissue. A wide scope of bone lesions
may present with an image of sequestrum. However, a
careful analysis of the clinical, biological, and radiological
findings including a combination of CT and advanced MR
sequences when needed may often enable to point toward a
limited number of conditions.

17.

18.

19.

20.

21.

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