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Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis

J. Herman Kan1, Melissa A. Hilmes1, Jeffrey E. Martus2, Chang Yu3 and Marta Hernanz-Schulman1

1 Department of Radiology and Radiological Sciences, Vanderbilt Children's Hospital, Vanderbilt University, 2200 Children's Way, Nashville, TN 37232.
2 Department of Pediatric Orthopedics, Vanderbilt Children's Hospital, Vanderbilt University, Nashville, TN.
3 Department of Biostatistics, Vanderbilt University, Nashville, TN.


Figure 1
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  		Fig. 1A —Postsurgical marrow edema without osteomyelitis in 3-year-old girl who had complete negative workup for infection. T1-weighted unenhanced, non-fat-saturated (A) and gadolinium-enhanced fat-saturated (B) coronal images of pelvis show focal linear marrow edema (arrows) consistent with marrow aspiration tract. MRI was requested after intervention because of continued concern for underlying osteomyelitis. When surgical approach is known, focal marrow edema (arrows) can be attributed to marrow aspiration only. Notice extensive myositis related to surgical intervention. This patient had no cause for her presenting symptoms after full workup.

 

Figure 2
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  		Fig. 1B —Postsurgical marrow edema without osteomyelitis in 3-year-old girl who had complete negative workup for infection. T1-weighted unenhanced, non-fat-saturated (A) and gadolinium-enhanced fat-saturated (B) coronal images of pelvis show focal linear marrow edema (arrows) consistent with marrow aspiration tract. MRI was requested after intervention because of continued concern for underlying osteomyelitis. When surgical approach is known, focal marrow edema (arrows) can be attributed to marrow aspiration only. Notice extensive myositis related to surgical intervention. This patient had no cause for her presenting symptoms after full workup.

 

Figure 3
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  		Fig. 2A —Postsurgical marrow edema outside osteomyelitis tract in 15-month-old boy with no evidence of osteomyelitis. T2-weighted sagittal (A) and proton density–weighted axial (B) fat-saturated images of distal tibia show round focal area of edema (arrows) consistent with anterior aspiration. When surgical approach for marrow aspiration is known, imaging findings can be attributed to intervention and not to early hematogenous osteomyelitis. This patient's final diagnosis was septic arthritis without concomitant osteomyelitis.

 

Figure 4
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  		Fig. 2B —Postsurgical marrow edema outside osteomyelitis tract in 15-month-old boy with no evidence of osteomyelitis. T2-weighted sagittal (A) and proton density–weighted axial (B) fat-saturated images of distal tibia show round focal area of edema (arrows) consistent with anterior aspiration. When surgical approach for marrow aspiration is known, imaging findings can be attributed to intervention and not to early hematogenous osteomyelitis. This patient's final diagnosis was septic arthritis without concomitant osteomyelitis.

 

Figure 5
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  		Fig. 3 —Osteomyelitis after initial surgical procedure in 6-month-old girl. T1-weighted fat-saturated axial image of right foot after IV administration of gadolinium shows large soft-tissue abscess (arrows) and intraosseous calcaneal abscess (arrowhead). This child initially underwent soft-tissue aspiration that yielded cellulitis with abscess (arrows). After MRI, patient underwent second intervention to drain intramedullary calcaneal abscess.

 

Figure 6
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  		Fig. 4A —Osteomyelitis after surgical procedure in 5-year-old girl who initially underwent elbow joint aspiration that was negative. T2-weighted (A) and T1-weighted (B) fat-saturated axial images of distal humerus show intramedullary and subperiosteal abscess (arrows). After MRI, patient was given diagnosis of osteomyelitis, and antibiotic regimen was changed accordingly. A second operation was not performed because child was improving clinically with antibiotics alone.

 

Figure 7
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  		Fig. 4B —Osteomyelitis after surgical procedure in 5-year-old girl who initially underwent elbow joint aspiration that was negative. T2-weighted (A) and T1-weighted (B) fat-saturated axial images of distal humerus show intramedullary and subperiosteal abscess (arrows). After MRI, patient was given diagnosis of osteomyelitis, and antibiotic regimen was changed accordingly. A second operation was not performed because child was improving clinically with antibiotics alone.

 

Figure 8
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  		Fig. 5A —Osteomyelitis with abscess after initial joint aspiration in 3-year-old boy who had undergone knee joint aspiration yielding clear bloody fluid that was negative for infection 1 day before MRI was performed. Unenhanced proton density–weighted fat-saturated sagittal (A) and T1-weighted axial fat-saturated gadolinium-enhanced (B) images show subperiosteal abscess (arrows) and diffuse small intramedullary abscesses. Small size of joint effusion (arrowheads) likely contributed to false-negative joint aspiration. After MRI, patient underwent second intervention to drain intramedullary and subperiosteal abscesses.

 

Figure 9
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  		Fig. 5B —Osteomyelitis with abscess after initial joint aspiration in 3-year-old boy who had undergone knee joint aspiration yielding clear bloody fluid that was negative for infection 1 day before MRI was performed. Unenhanced proton density–weighted fat-saturated sagittal (A) and T1-weighted axial fat-saturated gadolinium-enhanced (B) images show subperiosteal abscess (arrows) and diffuse small intramedullary abscesses. Small size of joint effusion (arrowheads) likely contributed to false-negative joint aspiration. After MRI, patient underwent second intervention to drain intramedullary and subperiosteal abscesses.

 

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