Acute Osteomyelitis
Osteomyelitis is primarily a disease of childhood and infancy, but a recent rise in its frequency is noted among the elderly Waldvogel et al. 1970 . The major offenders are Staphylococcus aureus in children, -hemolytic streptococcus, S. aureus and Escherichia coli in neonates, and gram-negative bacilli in adults and drug abusers. One study of 348 adult patients with osteomyelitis by Waldvogel and Papageor-giou 1980 revealed that S. aureus, enteric species, and streptococcal organisms are...
Temporomandibular Joint
Fig. 10.41A, B Rheumatoid apophysitis in the lumbar spine. A Right posterior oblique radiograph of the lower lumbar spine in a 63-year-old woman with rheumatoid apophysitis of L3 and L4 vertebrae shows articular blurring and periarticular bone erosions open arrows . B Posterior pinhole scintigraph reveals moderately increased tracer uptake in L3 and L4 apophyseal joint on the right arrows . Note the typical astride position of the apophyseal joint at this level The temporomandibular joints are...
t
- v lt 1 CilJtr Ki i''Iii.ii' 4 lt . Iii.- . , 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...
A History of Nuclear Bone Imaging
Conceptually, the nuclear imaging of bone can be dated from the mid-1920s when the notion of bone-seeking elements evolved from the clinical observation of radium-related osteomyelitis and bone necrosis Blum 1924 Hoffman 1925 . Shortly following successful isolation by the Curies, radium was processed to produce self-luminous materials to be painted on watch dials and instrument panels. During the painting of such radioactive materials with small brushes, workers habitually pointed the brush...
Shoulder Uiu
The shoulder has three different joints the gle-nohumeral joint, the acromioclavicular joint, and the coracoclavicular joint. The last of these is a variant joint between the coracoid process and conoid process of the clavicle. Furnished with a bursa it is the site of coracoclavicular ligament attachment, and its prevalence is 0.8 Gumina et al. 2002 . Rheumatoid arthritis is common in the first two joints, but is rare in the last whose existence itself is rare Lehtinen et al. 1999 ....
Acute Infective Periostitis
Acute infective periostitis is primary invasion of the periosteal cloak that covers the cortex. The infective products first accumulate beneath and raise the periosteum, subsequently spreading to the cortex and endosteum in succession. Radiographically, the raised and stimulated periosteum reacts with new bone formation Fig. 6.17A . Ordinary bone scintigraphy shows intense uptake that is simply homogeneous without a textural pattern Fig. 6.17B . However, pinhole scanning separates the seemingly...
B 1
Fig. 9.34A, B Osteoarthritis in the ulnar side of the wrist. A Dorsopalmar radiograph of the right wrist in a 41-year-old female shows sclerosis in the distal radial epiphysis with narrowing of the radiocarpal joint and the lunate -triquetral joint R radius, L lunate, T triquetrum . B Dorsal pinhole scan reveals intense tracer uptake in the radiocarpal joint lower arrow and the lunate-triquetral joint upper arrow uptake in the joints with severer pathological change and vice versa Fig. 9.35B ....
Tuberculous Arthritis of Peripheral Joints
Tuberculosis in the peripheral joints runs an insidious, chronic course as tuberculosis elsewhere. For the most part, the mode of infection of tuberculous arthritis is blood-borne with a primary focus usually in the lung. It may also arise from direct contamination with tuberculosis in the neighboring bone. Granulomatous tissue and pannus erode and dissolve articular cartilages and subchondral bones, causing irregular narrowing and disfiguring. Tuberculosis affects any joint Enarson et al. 1979...
Rheumatoid Arthritis
Rheumatoid arthritis is a fairly common systemic disease of multifarious and obscure etiologies, affecting primarily the synovial membranes of the joints in the appendicular and axial skeleton. It has a notorious predilection for the small joints of the hands and feet although the large joints of the wrists, knees, elbows, shoulders, and sternum are not exempted. The involvement is typically polyarticular and symmetrical. In the spine, the cervical vertebrae, particularly the atlantoaxial...
Hip
The hip is a ball-and-socket joint that permits multiaxial movement. It is surrounded by a dense, strong, fibrous capsule. Along with the knee, the hip joint is the most typical site of os-teoarthritis. Clinical symptoms are rotation or extension difficulty and pain that may be referred to the buttock, thigh, groin, greater tro-chanteric region, and knee. The radiographic features, as in all other joints, include articular narrowing, osteoscle-rosis, osteophytosis, subchondral cystic change,...
Manubriosternal Joint
Osteoarthritis also affects the manubriosternal joint, which is one of the largest fibrocartilagi-nous articulations. Degenerative arthritis mainly involves the central portion of the articular fibrocartilage with resultant articular narrowing and periarticular eburnation. Radiographically, the manubriosternal joint shows diffuse or partial narrowing with irregular sclerosis of the subchondral bones. Occasionally, the joint may be totally closed Fig. 9.30A . Conventional or computed tomography...
Decubitus Ulcer Bedsores
Decubitus ulcers are the breakdown of soft tissue due to prolonged physical pressure in patients kept lying too still for a prolonged period of time. It most commonly occurs in paralyzed patients and the debilitated elderly. Although other sites such as the elbows, heels, and shoulders are involved, the great majority of ulcers develop over the sacrum, ischial tuberosities, and femoral trochanters and buttocks. Local soft-tissue infection and bacteremia are common accompaniments. Staphylococcus...
Osteomyelitis of the Spine
Osteomyelitis of the spine pyogenic spondyli-tis typically affects adults. The main causative agents include S. aureus and streptococcus, and rarely gram-negative bacilli and salmonella. Pyogenic spondylitis may result from the direct implantation of organisms at the time of operation. However, in the vast majority the infection is blood-borne. The organisms are introduced through the arterial rather than venous pathway, and the early foci are located in the subchondral zone or the endplate of...
Wrist
The involvement of the radiocarpal, distal radioulnar, and prestyloid compartments Resn-ick 1974 and the pisiform-triquetral compartment Resnick 1976 is characteristic of rheumatoid arthritis of the wrist in early stages. While pinhole scans demonstrate significant tracer uptake in the radiocarpal, distal radioul-nar, and pisiform-triquetral compartments Fig. 10.12A radiographic alterations are subtle and occasionally doubtful Fig. 10.12B . The Fig. 10.11A, B Extremely intense tracer uptake in...
Neonatal and Infantile Osteomyelitis
Osteomyelitis and pyarthrosis are not common in infants and children. Nevertheless, these constitute important causes of chronic illness and serious deformity that last a long time. The symptoms of infantile, especially neonatal, skeletal infections are peculiarly subtle, usually manifesting as pseudoparalysis of a limb at most and fever only in half of cases Fig. 6.17A-C Acute infective periostitis. A Anteroposterior radiograph of the right lower leg in an 18-year-old girl with multiple bone...
Hand Fingers
The early alteration of rheumatoid arthritis has been described to initiate from the second and third metacarpophalangeal joints and the third proximal interphalangeal joint Fig. 10.10A . As shown in this case, however, the synchronous involvement of the wrist is common. Indeed, wrist involvement is as characteristic and heralding as digital involvement, or is even predominant during the early stages of the disease Hendrix et al. 1987 . Radiography reveals erosion, articular narrowing, and...
Osteomyelitis in Diabetic Foot
Diabetic foot denotes a complex bone and joint disorder that involves the foot in patients with longstanding diabetes. Infection directly extends from either contiguous cellulitis or infected skin ulcers or is mediated by the combination of circulatory, neuropathic, and degenerative alterations. Arteriosclerosis and occlusion, and resultant osteonecrosis are common complications of diabetes mellitus. In diabetics it is often difficult to distinguish between primary and secondary osteomyelitis...
lV ft
Fig. 6.32A, B Classic osteolytic manifestation of long bone tuberculosis with abscess and unimpressive reactive bone change. A Dorsoventral radiograph of a 41-year-old female with cystic tuberculosis in the right distal radius shows a poorly defined ovoid radiolucency open arrow with reactive sclerosis in the ulnar side solid arrow . B Dorsal pinhole scan shows intense tracer uptake with a photon defect due to the abscess open arrow . Intense uptake is mainly in the ulnar side of the lesion...
OssificationofthePosterior Longitudinal Ligament
Ossification of the posterior longitudinal ligament OPLL is an idiopathic disorder of the spine, in which calcification or ossification of various lengths occurs in the posterior longitudinal ligament. The middle cervical spine, T3 through T6, is most commonly affected. Pathologically, the condition is characterized by bony overgrowth of the ligament that is attached to the posterior surface of the vertebral body and intervertebral disk, compressing and flattening the spinal cord behind. The...
Pathogenesis
In the hematogenous form, the infective process classically starts in the metaphysis of long bone by the lodgment of organisms in endarteries, in which a slow blood flow facilitates their entrapment. As bone and bone marrow become the loci of bacterial proliferation, tissues Fig. 6.1A-C Schematic presentation of changing vascular supplies in long bone according to the three different age groups. Basically, the main blood supply to long bone ends derives from the nutrient artery. A In an infant...
and 67Ga Citrate Scintigraphy in Skeletal Infections
Acute infection of bones and joints can be diagnosed using 99mTc-MDP scintigraphy reinforced with nuclear angiography and the pinhole technique. However, white blood cells labeled with 111In or 99mTc are employed for more specific diagnosis of bone infection superimposed on fracture, operative wound, or prosthesis. One latest clinical study has confirmed the accuracy of 111In-leukocyte scintigraphy in the diagnosis of posttraumatic and postoperative cranial and spinal infections Medina et al....
Sternum
The sternum is provided with three articulations the paired sternoclavicular joints and the single manubriosternal joint. The former joints consist of the medial end of the clavicle and the clavicular notch along with the superior surface of the first costal cartilage and articular disk. The manubriosternal joint is mostly symphysis and partly synovial with cavitation created by disk absorption. The periarticular bony surfaces are covered by hyaline cartilage and connected by a fibrocartilage...
Diffuse Idiopathic Skeletal Hyperostosis
DISH, previously known as ankylosing hyperostosis of the spine and Forestier's disease, is characterized by bony proliferation at the site of tendon and ligament attachment to bone entheses , calcification and ossification of the anterior longitudinal ligaments, and diskover-tebral osteophytosis. This is a common but not insignificant disease of the spine and extraspinal skeleton. The etiology has not been established, but some investigators consider that it may be associated with degenerative...
Transient Synovitis of the Hip
Transient synovitis is a self-limited, nonspecific, inflammatory disease, typically affecting the hips in children aged between 3 and 10 years. Boys are affected much more commonly than girls. It occurs frequently after a respiratory tract infection. Erythrocyte sedimentation rate and white blood cell count are mostly normal. Other terms for the condition include irritable hip syndrome, observation hip, transitory arthritis, transitory coxitis, and simple serous coxitis. The etiology is not yet...
Pyarthrosis and Abscess of the Sacroiliac Joint
The sacroiliac joint may be infected through the hematogenous route, from a contiguous focus, or by direct bacterial implantation from Fig. 8.16A, B Acute infective arthritis of the elbow. A Lateral pinhole scan of the right elbow in a 31-year-old male shows intense tracer uptake in the radial head rh , olecranon base ob , and olecranon fossa of . B Lateral radiograph reveals diffuse blurring of the joint with thickening of the cubital soft tissue overlying the olecranon arrowheads Fig. 8.16A,...
Odontogenous Osteitis of the Mandible Periapical Abscess
Inflammation or infection about the dental root apex is one of the most common conditions in the mandible that manifests as intense tracer uptake. The condition is also important clinically since it occasionally progresses to alveolar abscess, apical granuloma, and cyst formation. The process may be either sterile or septic with a septic source usually in the infected dental pulp. Fig. 7.14A, B Early radiation-induced osteitis in the mandible 2 months after 65 Gy irradiation with 6 MeV...
Sympathetic Synovitis
Sterile sympathetic synovitis may be created in a joint in reaction to osteomyelitis in the juxtaar-ticular bone, for example, in the hip. This type of synovitis has also been known to be triggered by an infective organism growing in a distant site as a hypersensitivity response Goldenberg 1983 . Radiography reveals joint capsular distension, occasionally with regional osteopenia. Pinhole scintigraphic features include diffusely Fig. 8.5A, B Wrapped bone sign in acute, serous, sympathetic...
Acromioclavicular Joint
Degenerative change of this joint is primarily related to aging. The disease may start as early as the second decade of life, becoming severe by the fifth decade de Palma 1957 . The disease causes discomfort or pain that may be aggravated by motion, radiating to the upper arm. Radiography in the early stage shows mild cortical thickening and subcortical osteopenia in the para-articular bones, giving rise to a pencil-line appearance and apparent articular widening Fig. 9.22A . With the progress...
Acute and Chronic Infective Osteitis and Cortical Abscess
Infective osteitis is suppurative infection of the cortical bone. It may be acute or chronic, and occurs either as an isolated disease Fig. 6.12 or a concomitant process to osteomyelitis Fig. 6.13 . Pathologically, the process is characterized by cortical bone suppuration and abscess formation. The intracortical localization is characteristic, and such a peculiar localization has been accounted for by the presence of an anastomotic vascular network of the dual blood supply from both the...
Spondylolysis
Spondylolysis refers to the bone defect in the pars interarticularis. It is caused by repeated trauma or physical stress to the biomechani-cally vulnerable lamina between the superior and inferior articular facets. Spondylolysis divides a vertebra into the superior and inferior segment. The former segment includes the vertebral body, pedicles, transverse processes, and superior articular facet and the latter the inferior articular facet, laminae, and spinous process. Spondylolysis is an...
A
Fig. 5.22A-D Examples of various artifactual extraosse-ous uptake in 99mTc-MDP scans. A Anterior scan shows free pertechnetate in the stomach arrow . B Diffuse tracer uptake in the lung upper arrows and stomach lower arrow due to hypercalcemia. C Normal 99mTc-MDP bone scan with confusing residual 99mTc-MIBI activities in the biliary tract upper arrow and colon lower arrow from MIBI cardiac scan performed 1 day before. D Tracer bypassed into the urinary bladder through a fistula between the...
Sclerosing Osteomyelitis of Garre
This is a rare nonpurulent variant of subacute or chronic osteomyelitis. Pathologically, the condition is characterized by prominent proliferation and thickening of the periosteum and spongy trabeculae, but with little pus formation, necrosis, or granulation tissue. The mandible is the typical site of involvement. When a long bone is affected the diaphysis is the site of predilection, and this finding contrasts with the metaphyseal predilection of acute osteomyelitis. Radiography shows diffuse...
Glenohumeral Joint
Osteoarthritis of the glenohumeral joint may be associated with aging, occupation, sports, or accidental trauma. Bone diseases such as epiphyseal dysplasia, crystal deposition, hemophilia, or alkaptonuria may also cause osteoarthritis in this joint. The usual pathological sequence is chondrolysis with articular narrowing, hypertrophy with eburnation and osteophyto-sis, and cystic formation. Radiography shows eburnation, marginal sclerosis, and cystic change with articular nar rowing most...
Limbus Vertebra
Limbus vertebra is the marginal dislocation of nucleus pulposus, another mode of disk her-niation. It occurs typically in the anterior or posterior edge of the vertebral body, radio-graphically manifesting as the division of a small fragment with a cleavage Fig. 9.60A . A fragment is not present in every case Fig. 9.61A . Pinhole scintigraphically, the lim-bus with sclerosis is characterized by intense uptake localized to the anterior or posterior edge of an endplate, beaking outward when Fig....
C
lamellated with well-developed Haversian canals but poorly formed marrow Ono et al. 1977 . The most typical lesion occurs in the cervical spine, although other levels are not ex empted. It is a fairly common disorder with prevalence rates of 2-4 in the middle-aged and older populations in Asian countries Ogata and Kawaguchi 2004 . The disorder may pass symptomlessly or cause numbness and tingling pain in the fingers, head and neck pain, and severe anesthesia of the trunk and lower extremities....
Osteitis Pubis
Osteitis pubis is a nonspecific inflammatory disease of the symphysis pubis. The involvement is symmetrical, but the unilateral type is not rare. It develops after delivery and a pelvic operation such as prostatectomy or bladder surgery, although idiopathic occurrence in men or nulliparous women has been reported Numaguchi 1971 Segal and Kellogg 1954 . The histological feature is simple bony condensation Rendich and Shapiro 1936 . Clinically, the postoperative type is painful, whereas the...
Ankle and Tarsal Joints
articular cartilage of the patella may be categorized as the surface type or the basal type. The former is age-dependent, and its incidence increases precipitously with age, predisposing to osteoarthritis in later years, and the latter is a disease of young adults with more or less self-limited symptoms and clinical course. Conventional radiography is of limited value in diagnosing this condition Lund and Nilsson 1980 , but arthrography and CT and MRI play a decisive role. Occasionally, simple...
Intervertebral Osteochondrosis
The spine has five different articulations the diskovertebral and apophyseal joints in throughout the spine, the costotransverse and costocorporeal joints in the thoracic spine, and the uncovertebral joints in the cervical spine. Of these, the diskovertebral joint is fibrocarti-laginous in type and others are synovial except for the uncovertebral joint that is mixed in type. Based on the principal site of involvement, diskovertebral degeneration can be divided into diskovertebral osteoarthritis...
Osteomyelitis in Flat and Irregular Bones
The irregular bone most often affected with osteomyelitis in adults is the spine this is discussed in detail below. The next most commonly affected bones are the pelvis, skull, and tarsal bones. Fig. 6.22A, B Brodie's abscess. A AP radiograph of the right distal femoral metaphysis in a 31-year-old male patient with Brodie's abscess shows irregular lucent defects surrounded by diffuse sclerosis. The defects are created by saucerization. B Anterior pinhole scan of the same infective lesion shows...
Degenerative Joint Diseases
Osteoarthritis Degenerative joint diseases include osteoarthritis, osteoarthrosis, osteochondrosis and others, and are the most common joint disorders that gradually disable patients. These recently receive greater attention because of the unprecedented prolongation of life expectancy and the availability of efficient prosthetic therapy. The terms describing degenerative joint diseases are many and used more or less loosely and even interchangeably. Osteoarthritis and osteoarthosis designate...
Wrist and Carpal Joints
The wrist radiocarpal joint is a biaxial and ellipsoid articulation formed between the distal end of the radius and the scaphoid, lunate, and triquetrum with triangular cartilage on the ul-nar side. The joint is lined by synovium and surrounded by fibrous capsule and radiocarpal ligaments. In addition, there are complex inter-carpal joints, interconnecting a the proximal carpal bones, b the distal carpal bones, and c the two carpal bone rows. Osteoarthritis of the wrist predominantly affects...
Navicular Accessory Joint
The characteristic radiographic features of osteoarthritis of the navicular accessory bone include irregular narrowing of the navicular and navicular-accessory synchondrosis or joint with the condensation of the accessory bone, mimicking avascular necrosis Fig. 9.50A . The accessory bone avidly accumulates tracer, attesting to the fact that dense accessory bone is not due to necrosis but stimulated bone Fig. 9.48A, B Osteoarthritis in the sesamoidal articulation of the first metatarsal head. A...
Generalized Osteoarthritis
Generalized osteoarthritis designates a multiarticular involvement pattern of five or more joints at one time with osteoarthritis. It is divided into primary and nodal type according to the absence or presence of Heberden's nodes. Kellgren et al. 1963 have reported high rates of its occurrence in both male relatives 36 and female relatives 49 compared to respec- Fig. 9.52 Value of whole-body bone scintigraphy in the diagnosis of generalized osteoarthritis. Anterior left and posterior right...
Pyogenic Arthritis Pyarthrosis
Pyogenic arthritis is a septic condition of a joint. As in acute osteomyelitis, acute pyarthrosis may result from a hematogenous spread of bacteria with direct synovial lodgment, b transphyseal across the growth cartilage spread of a primary infective focus in the long-bone metaphysis, c contiguity, or d penetration or operation. The most common offenders are micrococci and gram-negative bacilli. In children, pyarthrosis has a predisposition for the large joints of the limbs, whereas bacterial...
Sternoclavicular Joint
The sternoclavicular joint is the synovial articulation between the medial end of the clavicle and the sternal clavicular notch, together with the upper part of the subjacent first costal cartilage. The movements and structures including the articular disk are much like those of the acromioclavicular joint. The fibrocartilaginous layer is much thicker on the clavicular surface than the sternal notch. This joint is also a common seat of osteoarthritis. Men are more frequently affected than...
Condensing Osteitis of the Clavicle
Originally described by Brower et al. 1974 as a clavicular version of osteitis condensans ilii and osteitis pubis, this entity is clinically characterized by painful swelling of the medial end of the clavicle again in young women of child- bearing age. Undue stress to the clavicle appears to be the cause. Pathology is not related to infection, neoplasm, or avascular necrosis. The main histological changes include apposi-tional trabecular thickening in the cancellous bone and periosteal...
Sternocostoclavicular Hyperostosis
Sternocostoclavicular hyperostosis or inter-sternocostoclavicular ossification is a painful, chronic, nonsuppurative inflammatory disease of the sternum. Pathologically, the condition is characterized by the prominent overgrowth of the sternum, clavicle, and upper anterior ribs with ossification of the adjacent soft tissue So- Fig. 7.9A, B Sternocostoclavicular hyperostosis. A Anterior conventional X-ray tomogram of the sternum in a 42-year-old man reveals a sawtooth-like synostosis between the...
Chondromalacia Patellae
Chondromalacia of the patella is a condition characterized by a series of degenerative changes that involve the cartilage and subchondral bone in the retropatellar facet. Clinically, two different types have been described on the basis Fig. 9.17A, B Chondromalacia patellae associated with osteoarthritis. A Medial pinhole scan of the right knee in a 70-year-old woman shows spotty intense tracer uptake typically localized in the upper posterior aspect of the patella surrounded by less intense...
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...
Knee
Fig. 9.13A, B Multicompartmental involvement in osteoarthritis in the knee. A Anterior pinhole scan of the right knee in a 35-year-old man shows multiple, asymmetrical areas of segmental, spotty, and patchy tracer uptake in the femorotibial compartments including the tibial tubercles and the proximal tibiofibular joint arrows with narrowed articular space arrowheads . B Anteroposterior radiograph reveals minimal marginal osteophytes arrowheads , the pointing of the tibial tubercles middle...