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EARLY ROENTGEN OBSERVATIONS IN

ACUTE OSTEOMYELITIS*
JOHN A. KIRKPATRICK,
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By MARIE A. CAPITANIO, M.D.. and M.D.

PHILADELPHIA, PENNSYLVANIA

H EMATOGENEOUS osteoni ‘eli tis con- may take place if not interrupted b’ body
tinues to be endemic in the pediat- defenses or altered by tilerapeutic melt-
nc age group. Ihe litiVent ofantibiotics illis sores. Initially there is an increase in tile
provided a means for c-tire but therap’ rate of bloot! flow to tile region with an
must be instituted early to be effective and associated arteriolar dilata tion. Capillar’
to prevent the serious complications of dilatation ant! increased capillar perme-
osteomyelitis. Early diagnosis is therefore ability then ensue with a subsequent out-
of paramount importance. When the classic pouring of fluid from the capillaries into
signs and symptoms of acute osteomvelitis the surrount!ing tissues. There is eventual
are present (i.e., local pain, swelling, heat slowing or stasis of the bloot! flow followed
and tenderness, fever anti leukocvtosis) the b the appearance of white blood cells into
diagnosis may be made by tile clinician the inflammatory focus. The suppurative
without difficult’. However, since the in- process results in local destruction of tra-
troduction of antibiotics there has been beculae anti eventually, if unabated, ma\
an apparent change in the character of spread throughout the in tramedullarv ca-
osteomvelitis.2 This is manifest by an in- nal producing widespread destruction of
creasing number of patients presenting trabeculae. The pus accumulating under
with a milt! or subacute illness with an in- pressure in the intramedullary canal ma
sidious onset of symptoms anti frequently rupture through the cortex via multiple
no associated systemic reaction. It is diffi- sinus tracts and elevate tile periosteum.
cult to make the diagnosis of osteomvelitis Chronic osteomyelitis is established lit that
in tilese patients on clinical evidence alone, point. During the destructive phase corti-
and other means for early diagnosis are cal bone may become devitalized and re-
necessary. ‘rile changes that can be appre- stilt in the formation of sequestra. An
cia ted roentgenographi c-ally in the early involucrum is formeti when bone is pro-
stages of osteom elitis, before there is visi- t!uced b the elevatet! periosteum. Rarely
ble bone destruction, are of considerable is the integrity of the periosteum violated
assistance in making the early diagnosis. b the suppurative process. A sympathetic
joint effusion may occur anti there may be
PA1’HO LOGY
extension of the suppurative process into
Hematogeneous osteomyelitis is an in- the joint, although the latter is unusual.’
flammatory process that begins in the bone
ROENTGEN OBSERVATIONS
marrow. Almost without exception the
primary site of involvement is at the ends Tile roentgen observations tiescri bed
of the long bones where growth is most here will be limited primarily to those
rapid. The rich blood supply and the nature changes that are seen before bone destruc-
of the structure of tile vessels at the meta- tion or periosteal new bone formation is
physis, end-arteries, pret!ispose to the visible.
lodgment of bacteria within the vessels in \Vithin the first 3 days after the onset of
this region.8 Once the nidus of illfection is symptoms, alterations in the roentgen
established, an integrated series of events appearance of tile soft tissues about tile

* From the Departments of Radiology and Pediatrics, St. Christopher’s Hospital for Children and l’emple University School of
Medicine, Philadelphia, Pennsylvania.

488
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I-ic. i. This 12 year old Negro male presented with local pain and tenderness over the distal metaphysis of
the right femur. (4) He had no systemic symptoms. The displacement of the deep lucent planes by the
local deep soft tissue swelling in relation to the medial metaphysis is best seen in the oblique projection
(C). The left knee (B and D) is normal.
 490 Marie A. Capitanio and John A. Kirkpatrick MARCH, 1970
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11G. 2. (4 and C) The right leg is normal. (B and D) The deep soft tissues of the left leg of this 6 year old
Negro male are enlarged and there is fluid in the ankle joint. No alteration in the bones is evident. At
surgery subperiosteai pus uilder tension was found and cultures of the aspirate and blood grew out Staphv-
lococcus aurcus, coagu lase positive.

metaph\-sis are visible. The first definite deep soft tissue swelling correlates well
Cilailge noteti is a small, local, deep, soft witil tile time that tile vascular changes are
tissue swelling in tile region of tile meta- occurring tluring tile early events of the
physis.3 Ihe osseous structures and remain- inflamnlatorv response. \\hen the local,
ing soft tissues are normal roentgeno- deep soft tissue swelling is visible OD tile
grapilicallv. The tleep soft tissue swelling is roentgenogram, tilere frequently will be no
contiguous with tile adjacent bone and is pus present when the bone is drilled. Tile
apparent OD tile roentgenogram by virtue surgeon observes, however, that the pen-
of the tlisplacement of the lucent deep osteum is thickenet! and tilat bleeding is
muscle plane away from tile bone (Fig. i, greater than usual. Cultures of the aspirate
zl-D). ‘File tlegree to which tile lucent often will grow the offend!ing organism.
plane is displaced by the deep soft tissue ‘Ihis early stage of osteomvelitis, before tile
swelling is fretluentl\’ small anti will not accumulation of an exutiate, is referred to
be appreciated unless roentgenograms of aS a metaphvsitis. Treatment at this stage
tile opposite extremity in identical pro- with surgery, appropriate antibiotics lilld
jections are availal)le for comparison. ‘he rest will usually abort the inflammatory
roentgen observation of tile metaphysea! process with no subsequent significant bone
 OL. io8, No. 3 Acute Osteomvelitis 491
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destruction resulting. Follow-up roentgen- muscles anti lucent planes are the first to
ograms may show a mild rarefaction 1fl tile be alteretl, followed later b\’ involvement
metaphysis anti slight peniosteal reaction, of the more superficial muscles and lucent
part of which is secondar\- to tile surgical planes (Fig. 2, 4-D). Superficial sub-
procedure. cutaneous soft tissue edema is the last
The seconti cllange ill tile soft tissues soft tissue change to be observetl (Fig. 3,
apparent roentgenographicallv occurs lifter J-D). Early 111 tiliS second stage the tlegree
the first few days following the onset of of enlargement of the tleep muscles may
symptoms. Ihis is manifested by swelling not be sufficientl great to detect on ph’si-
of the muscles an(l obliteration of the lucent cal examination, although the change can
planes between the muscles.4_6,10 The deep be visualized roen tgenographicall’ (Fig.
 492 \llinie A. (apitanio lint! John A. Kirkpatrick M RCH, 1970
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3:-’

‘-&.--

I’-
3-

I..

I-u;. 4. (4) There is acute osteomvelitis of the right knee of this 74 year old Negro male. The degree of soft
tissue swelling in relation to tile medial femoral metaphysis was not as obvious clinically as that at the
wrist. (B) The left knee is normal.

, 1-1-F). \Vhen the bone is dnilletl lit this destruction anti peniosteal new bone for-
time, pus is obtained, as tile suppurative mation is not seen until 10 or 1 2 days lifter
phase is well established. Although con- tile onset of symptoms or after treatment
sitlerable bone destruction is present dii ring (Fig. 3, E anti I; antI 4, G-K). The amount

this phase it is not visible roentgenographi- of bone destruction that is visible roent-
c-ally. lile only bone change that may be genographically b- the enti of tile seconti
appreciliteti on the roentgenogram is a week is considerably less thlin tile amount
mild local rarefaction at tile metaph\sis of actual bone destruction present.
which is titie in part to the il\peremia pres-
S U MMA RY
ellt as well as to tile actual early t!estruc-
tion of trabeculae (Fig. , 11--D). Treatment, The roentgen examination can be very
if institutetl early in this stage, can prevent helpful in making the early tiiagnosis of
maSSive destruction of bone and serious osteonlyelitis. \Vithin the first 3 tla\’s after
com ph c-a tions. the onset of symptoms, soft tissue changes
The classic roentgell picture of bone are visible roentgenographically. A local
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Fic.
.
(C and
I

E)
Osteomyelitis
of
the right
wrist.
(D and F) Normal
left wrist.
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1-ic.
4.
(1
and
LL
K) Roentgenograms
__

but no visible
of the right wrist,
bone
3 weeks
k

destruction.
following
treatment,
show
periosteal
new
bone,
 \OL. 108, No. 3 Acute Osteomvelitis 495
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i-ic. . This 4 year oiti white female gave a history of a sore throat I week prior to onset of limping anti 2 weeks
prior to the roentgenographic examination. (4 and D) Swelling of both the deep and superficial soft tis-
sues of the right leg is present and there is an area of bone destruction at the metaphysis of the distal
tibia. Fluid is present in the ankle joint. (B and C) The normal left leg is shown for comparison. At surgery
the periosteum was distended by a granulomatous material indicative of a chronic infection.
 496 Marie A. Capitanio and John A. Kirkpatrick MARCH, t9#{243}

deep soft tissue swelling adjacent to the Medical Publishers, Inc., Chicago, 1967.

2. Editorial. Changed character of osteomyelitis.

metaphysis of a growing bone without
Brit. M. 7., 1967,3, 255-256.
superficial edema should alert the radio!-
3. FERGUSoN, A. B., JR. Orthopedic Surgery in
ogist to the possibility of osteomyelitis. Infancy and Childhood. Second edition.
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The diagnosis is almost certain if there is Williams & Wilkins Company, Baltimore,
also local tenderness clinically. Several 1963.
days after the onset of symptoms, swelling 4. GIEDI0N, A. Soft tissue changes and radiologic
early diagnosis of acute osteomyelitis in early
of the deep muscles and obliteration of the
childhood. Fortschr. a. d. Geb. d. R#{246}ntgen-
lucent planes between the muscles are
strah/en ii. d. Nuk/earmedizin, 1960, 93, 455-
visible roentgenographically, even though 466.
the enlargement of the deep muscles may . GRIFFIN, P. P. Bone and joint infections in
not be appreciated clinically. In order to children. Pediat. C/in. North 4merica, 1967,

appreciate the soft tissue changes that 14, 533-548.

6. JORUP, S., and KJELLBERG, S. R. Early diagnosis
occur early in osteomyelitis it is most im-
of acute septic osteomyelitis, periostitis and
portant that the normal as well as the arthritis and its importance in treatment.
abnormal sitle be examined roentgeno- jicta radio/., 1948, 30, 316-325.
graphically. 7. Roiiius, S. L. Pathology. Third edition. W. B.
Saunders Company, Philadelphia, 1967.
Marie A. Capitanio, M.D. 8. SCHINZ, H. R., BAENSCH, W. E., FRIEDL, E., and
Department of Radiology
UEH LINGER, E. Roengten Diagnostics. Volume
St. Christopher’s Hospital for Children
i, Skeleton. Grune & Stratton, Inc., New
2600 North Lawrence Street
York, 1951.
Philadelphia, Pennsylvania 19133
9. STEINBACH, H. I. Infections of bones. Seminars
Roentgenol., 1966, I, 337-369.
REFERENCES
JO. SURRATT, R. R. Radiologic seminar XLI: early
i. CAFFEY, J., and SILVERMAN, F. N. Pediatric acute hematogenous osteomyeiitis. 7. Mis-
X-Ray Diagnosis. Fifth edition. Year Book sissippi M. 4., 1965, 6, 350-351.