IMAGING

The radiological diagnosis of

infection

appearances, and indications and limitations of imaging modalities used in diagnosis of infections with pictorial examples.

Osteomyelitis
Infection of the bone or bone marrow is a difficult condition to
treat and despite advances in imaging it is a challenge to detect
and diagnose it at an early stage. Treatment when instituted at an
early stage significantly increases cure rate and reduces complications and associated morbidity.
Bacterial aetiology is the most common, with Staphylococcus
aureus being the predominant causative organism. Haemophilus
influenzae and group B streptococcus are common causes in
children; gram-negative bacteria (such as E. Coli), anaerobes in
adult and diabetics; Staphylococcus epidermidis in intravenous
drug abusers and patients with joint replacements. Viruses, fungi
and protozoa are also recognized as causative organisms
particularly in immunocompromised patients.
Osteomyelitis may spread via the haematogenous route
(predominantly seen in children), post-traumatic or contiguous
spread (common in adults). The majority of osteomyelitis involves long bones, vertebral column and bones of the feet.
Acute osteomyelitis is of rapid onset, commoner in children and
mainly affects the metaphysis of long bones such as the tibia, femur
and humerus. Infection triggers an inflammatory response leading
to increased intramedullary pressure causing thrombosis of vessels. This causes progression of infection and spread of exudate
leading to periosteal stripping and new bone formation (also
known as involucrum). Infection may also cause bone infarction
and formation of sequestrum, which is a dead, devascularized
bone fragment. A sequestrum is a continual source of infection and
if not excised can lead to formation of cloacae (opening in the
involucrum), sinus tract formation and soft tissue abscess.
Subacute osteomyelitis is of insidious onset and more difficult
to diagnose because of mild symptoms and lack of systemic reaction. It can often mimic other benign and malignant conditions
most common being bone tumour. Broadies abscess is a type of
subacute osteomyelitis and particularly common in children,
typically boys and tends to involve the metaphysis of long bones
especially the distal or proximal metaphyseal ends of the tibia.
Chronic osteomyelitis often follows inadequately treated acute
osteomyelitis, previous trauma or orthopaedic procedures. In
chronic osteomyelitis the affected long bone demonstrates focal
cortical thinning with small intramedullary cysts. There may be
cortical disruption with formation of cloacae from which a discharging sinus extends to the skin.
Differential diagnosis for osteomyelitis includes trauma,
benign bone tumours such as eosinophilic granuloma and
osteoid osteoma; malignant bone tumours such as Ewings sarcoma and osteosarcoma. Crystal arthropathy can have similar
clinical and imaging features resembling chronic osteomyelitis.
Certain conditions predispose to osteomyelitis. These include
poorly controlled diabetes mellitus, immunosuppression, chronic
renal failure patients on dialysis, intravenous drug abusers,
sickle cell disease, injury and previous orthopaedic surgery.

Vineet Bhat
Harun Gupta

Abstract
Musculoskeletal infections can involve bone, joints, muscles and soft tissues. The interpretation of imaging in musculoskeletal infections can be a
diagnostic challenge and requires an integrated approach with clinical details and blood inflammatory markers. Imaging also plays a vital role in
treatment planning and follow up. Conventional plain film radiography
is still the cornerstone, which provides an overview of the bone and surrounding soft tissue pathology and should routinely be the first imaging
procedure in patients with suspected musculoskeletal infection. The
sensitivity of radiographs for the detecting of acute osteomyelitis is
limited. Ultrasound can be used to assess soft tissue collections, joint effusions, and foreign body localization. It is invaluable in providing guidance for diagnostic joint aspiration, biopsy or therapeutic drainage of a
soft tissue abscess/collection. CT scans are useful in providing bony detail
and are particularly useful for evaluation of presence of sequestrum and
in cases where MRI is contraindicated. MRI provides excellent anatomical
details and evaluates both the soft tissues and bones and is the most
sensitive and specific imaging modality for evaluating musculoskeletal
infection. Radionuclide imaging can be helpful in cases of acute osteomyelitis and multifocal infection and has a high negative predictive value
when normal.

Keywords imaging; infection; musculoskeletal; osteomyelitis; septic

arthritis

Introduction
Musculoskeletal infections can involve bone, joints, muscles or
soft tissues and are commonly encountered in clinical practice.
History, clinical examination and blood tests are helpful but the
diagnosis can be challenging and various imaging modalities are
routinely used for confirmation, localizing site, extent and
severity of infection, guiding intervention and follow up. There is
a plethora of imaging tests such as plain radiograph, CT, MRI,
ultrasound and radionuclide to choose from but no single test is
optimal for every situation, and each patient is best served with
an individualized approach.
The most important prognostic factor in patients with
musculoskeletal infections is the delay in diagnosis and hence
starting the appropriate therapy.
This article will discuss the common musculoskeletal infections encountered in orthopaedic practice, their radiological

Vineet Bhat MBBS MRCS FRCR Consultant Musculoskeletal Radiologist,

University Hospital of Wales Heath Park, Cardiff, UK. Conflict of interest:
none.

Septic arthritis

Harun Gupta MBBS MD DNB MRCP FRCR Consultant Musculoskeletal Radiologist, Leeds General Infirmary MSK Radiology Department, Leeds, UK.
Conflict of interest: none.

ORTHOPAEDICS AND TRAUMA --:-

With no history of trauma or recent instrumentation of a joint,

septic arthritis is usually secondary to haematogenous spread.

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Please cite this article in press as: Bhat V, Gupta H, The radiological diagnosis of infection, Orthopaedics and Trauma (2014), http://dx.doi.org/
10.1016/j.mporth.2014.03.001

IMAGING

osteomyelitis. Though not the most accurate, they provide an

overview of the region of interest and may suggest the diagnosis.
The earliest radiographic abnormality is soft tissue swelling and
loss of distinction of soft tissue planes. Typical early bony
changes include: periosteal thickening, lytic lesions, endosteal
scalloping, osteopenia, loss of trabecular architecture, and new
bone apposition.1 Osteomyelitis must extend at least 1 cm and
compromise 30e50% of bone mineral content to produce
noticeable changes on plain radiographs, which takes approximately 2e3 weeks to develop.2 The sensitivity of plain radiography ranges from 43% to 75%, and the specificity from 75% to
83%.3 Though helpful when positive, a negative study does not
exclude osteomyelitis.
In childhood the metaphysis is the usual site of infection.
After infancy the physeal plate prevents infection spreading to
the epiphysis. Increased intramedullary pressure leads to periosteal stripping and vascular thrombosis. This in turn leads to
bone infarction and formation of sequestra.3 A sequestrum is a
continual source of infection and if not excised can lead to formation of cloacae, soft tissue abscess and sinus tract formation.
During the subacute and chronic stages of osteomyelitis single or
multiple lucencies may develop affecting the extremes of tubular
long bones indicating abscesses. Brodies abscess is particularly
common in children, typically boys and tends to involve the
metaphysis of long bones especially the distal or proximal metaphyseal ends of the tibia (Figures 1e3).4

Figure 1 AP Radiograph of the left wrist shows subtle periosteal reaction

in the ulnar aspect of the distal radial metaphysis (black arrow) indicative
of acute osteomyelitis.

Large joints with abundant blood supply to the metaphyses are

most prone to bacterial infection, the most commonly affected
joints being the shoulder, hip, and knee. Septic arthritis may
occur at any age and requires prompt diagnosis and treatment to
prevent irreversible joint damage. Aspiration of effusion in acute
cases or synovial biopsy in chronic cases and their microbiological analysis should be performed for definitive diagnosis. S.
aureus, Streptococcus pneumoniae and -Haemolytic Streptococci
are common causes of acute septic arthritis. Mycobacterium
tuberculosis and fungi are important causes of chronic septic
arthritis.
The rate of infection for primary hip and knee replacement is
approximately 1% and 2% respectively. About one-third of these
infections develop within 3 months, another third develop within
1 year, and the remainder develop more than 1 year after surgery. Rate of infection for revision surgery is higher at 3% for
revision hip and 5% for revision knee surgery, commonest organisms being S. epidermidis (31%) followed by S. aureus
(20%).
Various imaging modalities used in the diagnosis of infection
are discussed below.
Figure 2 AP radiograph of the right wrist shows a well defined lucent area
in the distal metaphysis of the radius (longer black arrow) with surrounding patchy loss of bone density in the distal metaphysis and the
adjacent epiphysis. Subtle periosteal reaction (short black arrows) is seen
in the ulnar aspect of the distal metaphysis of the radius.

Conventional radiography
Radiographs are inexpensive and readily available and should
form the first step in the imaging assessment of suspicion of

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IMAGING

It can be used to evaluate superficial and deep soft tissue and

joint infections. These include cellulitis, necrotizing and nonnecrotizing fasciitis, abscesses, pyomyositis, infective bursitis,
infective tenosynovitis, foreign bodies, post-operative infections
and septic arthritis.5 Ultrasound is not the preferred modality for
assessment of osteomyelitis, as it cannot visualize beyond the
outer cortex.
Cellulitis
Ultrasound demonstrates irregular, ill-defined hyperechoic fat
with blurring of tissue planes with intervening hypoechoic strands
indicating oedema. However this does not differentiate between
infectious or non-infectious causes of soft tissue oedema. If left
untreated cellulitis may progress to form an abscess.
Abscess
An abscess is seen as an irregular fluid filled hypoechoic area
with posterior acoustic enhancement. The collection may contain
variable amount of echogenic debris. Dependent layering of
echogenic particles can give rise to fluidefluid levels within the
abscess. Mild probe pressure may indicate the liquid nature of
the collection by movement of the echogenic particles within the
collection. Doppler examination often demonstrates increased
vascularity in the abscess wall and surrounding tissues
(Figure 4).
Septic arthritis
With septic arthritis the initial clinical examination and plain
radiographs may be unhelpful in excluding the condition.
Although ultrasound scan of the affected joint can confirm the
presence of joint fluid, it cannot differentiate non-infected joint
effusion from septic arthritis and microbiological evaluation of
joint fluid is necessary to confirm the diagnosis. Ultrasound
guided joint aspiration provides fluid for analysis with lesser risk
of contaminating other anatomical compartments. In a painful
prosthetic joint, demonstration of a large joint effusion with extra
articular fluid collections at US has been shown to be highly
suggestive of septic arthritis (Figure 5).5

Figure 3 AP radiograph of the right knee shows a well defined oval

lucency in the proximal metaphysis of the tibia (black arrow) with a narrow zone of transition indicative of a Brodies abscess.

Ultrasound

Post-operative infections
Post-operative infections involving orthopaedic hardware such
as metal plates, nails and joint replacements can limit imaging

Ultrasound is a low cost, non-ionizing technique, which is widely

available. It may be used as a primary imaging technique or as an
adjunct with other imaging techniques. Apart from its use in
diagnosis, it can be used to perform aspiration, drainage or
biopsy.

Figure 5 Ultrasound scan of the right hip shows a joint effusion (arrow head)
with a distended joint capsule (white arrows). However, ultrasound cannot
differentiate non-infected joint effusion from septic arthritis and microbiological evaluation of joint fluid is necessary to confirm the diagnosis.

Figure 4 A large well defined hypoechoic collection with high echogenic

debris noted in the subcutaneous tissues of the posterior aspect of the
right arm consistent with an abscess.

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IMAGING

Figure 6 Radiographs of the right elbow shows evidence of infected total elbow replacement prosthesis. There is peri-prosthetic lucency (black arrows),
areas of cortical thinning (arrow head), cortical irregularity and sub-periosteal new bone formation (smaller black arrows). Soft tissue swelling around the
elbow joint is also noted.

detection of osteomyelitis, demonstrating the intraosseous and

soft tissue extent of the infection and helping in surgical planning
and monitoring antibiotic therapy. The anatomical extent of
osteomyelitis can be clearly demonstrated using multi-planar
image planes, with detection of skip lesions. Additional abnormalities such as cortical erosions or perforation, periosteal new
bone formation, soft tissue involvement, abscess, bone sequestra
and sinus tracts are demonstrated with this modality, although
sequestra are better demonstrated by CT with multi-planar
reconstructions.
Acute osteomyelitis shows areas of loss of normal high signal
intensity of the marrow fat on T1-weighted sequence and
increased signal intensity on T2-weighted/STIR (short T1 inversion recovery) sequences and can be appreciated as early as 3e5
days after infection. Similar signal characteristics may be
observed in chronic active infection. However chronic indolent
infections tend to be better defined, with geographical bone
destruction.
Osteomyelitis may be complicated by the development of subperiosteal and soft tissue abscesses. Soft tissue abscesses are
usually round or oval mass lesions, which displace the adjacent
soft tissues and have a thick, irregular wall and may contain gas.
Abscesses demonstrate low signal on T1-weighted sequence and
high signal on T2-weighted sequence. On gadolinium enhanced
sequences no enhancement of the non-vascular abscess collection is noted. The irregular thick wall of the abscess cavity may
enhance, indicating presence of vascularized inflammatory tissue
surrounding the abscess cavity.
Chronic osteomyelitis is characterized by bone remodelling
where cortical changes predominate and the marrow signal
changes become non-homogenous. An important feature of
chronic active osteomyelitis is the formation of sequestra.
Sequestra if present will appear as a central area of low signal
intensity on all sequences and do not enhance on gadolinium
enhanced scans. Sinus tracts may be present in chronic

evaluation by CT and MRI due to artefacts. Ultrasound is less

affected and can be helpful in evaluating fluid collections or joint
effusion and guide aspiration for microbiological diagnosis
(Figure 6).6

Computed tomography (CT)

Multislice CT allows quick scanning times and provides excellent
definition of cortical bone and reasonable evaluation of surrounding soft tissues. CT provides an excellent analysis of
compartmental anatomy; thereby helping to distinguish among
the various types of musculoskeletal infections and guide treatment options.3 Multi-planar reconstructions are helpful in characterizing the most subtle osseous changes in osteomyelitis. Soft
tissue reformats for compartmental anatomy can be particularly
helpful in patients with absolute contraindication for MRI
examination.
In acute osteomyelitis, changes seen on CT include cortical
destruction, periosteal reaction and blurring of soft tissue
planes.7 However CT it is less desirable than MRI because of
decreased soft tissue contrast as well as exposure to ionizing
radiation. CT is effective in the evaluation of subacute and
chronic osteomyelitis. Features of chronic osteomyelitis include
irregular cortical thickening/sclerosis, cloaca and chronic draining sinus. An important role of CT is to delineate sequestra which
may be masked by the thickened irregular cortical bone on
conventional radiographs. CT is the method of choice for guiding
bone biopsies and aspiration/drainage of deep collections. Presence of metallic orthopaedic hardware can limit CTs ability in
evaluating subtle bony abnormalities due to artifacts (Figures 7
and 8).

MRI
MRI due to its high sensitivity (over 90% in detection of osteomyelitis) and spatial resolution is the best modality for the

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IMAGING

7-1

7-2

7-3

7-4

Figure 7 7-1, 7-2, 7-3: CT right leg with coronal and sagittal reformats shows evidence of chronic osteomyelitis with patchy sclerosis of the tibia. There is a
chronic draining sinus (cloaca e yellow arrow) with sequestrum (black arrows) in the sinus tract. 7-4: MRI coronal T1 post contrast image with intraosseous sinus tract (white arrow) and sequestrum (white arrow head).

osteomyelitis which appears as linear high signal areas which

extend from the medullary cavity into the soft tissues. Brodies
abscess presents as a well defined intraosseous collection, low on
T1-weighted sequence and high on T2-weighted sequence with a
rim of intermediate signal intensity representing vascularized
granulation tissue which enhances on gadolinium scans.
It may be difficult to identify diminished signal of infected
bone marrow on T1-weighted sequence in children and young
adults because of normal haematopoietic marrow in this age
group. Similar diagnostic challenge is also seen in adult patients
with medical conditions leading to excessive haematopoiesis. Fat
suppressed fluid sensitive sequences are more sensitive for
identifying osteomyelitis in these situations.8
Limitations of MRI are its inability to distinguish infectious
from inflammatory changes. Non-infectious disorders like infiltrative neoplasms, or eosinophilic granuloma may mimic bone
infection. Traumatic bone contusion, insufficiency fractures, and
transient osteoporosis of the hip may show a non-specific pattern
of bone oedema with signal characteristics similar to osteomyelitis. MRI may overestimate the extent and duration of infection.
In acute osteomyelitis differentiating soft tissue extension of

ORTHOPAEDICS AND TRAUMA --:-

Figure 8 CT abdomen/pelvis shows a large joint effusion (/) around the

right prosthetic hip joint. Erosion of the lateral aspect of the cortex of the
proximal femur (/) is also noted.

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IMAGING

9-2

9-1

Figure 9 9-1 and 9-2: 9-1 Plain radiograph of the right shoulder demonstrating septic arthritis with osteomyelitis causing destruction at the glenohumeral
joint and greater tuberosity: 9-2 is MRI right shoulder coronal fluid sensitive fat suppressed sequence demonstrating glenohumeral septic arthritis with
fluid within the joint and joint margin destruction (white arrows). Bony oedema in the humeral head and surrounding soft tissue oedema.

MRI has a sensitivity of 90% and specificity of 83% for pedal

osteomyelitis and soft tissue infections.9 On MR imaging, T1weighted imaging shows that involved bone marrow fat signal
is replaced by low signal intensity. Tracking a sinus from a skin
ulcer leading to an underlying bone can often lead to the site of
osteomyelitis. Periosteum in the involved bone may be elevated
with a high signal area between the periosteum and cortical bone
indicating a sub-periosteal abscess. Fluid sensitive fat suppressed
sequences are excellent in demonstrating cellulitis, soft tissue
abscesses, sinus tracts, and bone marrow oedema. Foreign
bodies can also be demonstrated well on MRI.
MRI with its excellent soft tissue resolution is extremely
valuable in diagnosing soft tissue abscesses, pyomyositis and
necrotizing fasciitis. Necrotizing fasciitis is a life threatening
emergency with a mortality and morbidity of 70%e80% and the
most important predictor of mortality is delay in diagnosis.10
This condition shows rapidly spreading progressive necrosis of
subcutaneous fat and fascia with presence of gas in the subcutaneous tissues as a distinguishing feature. This is associated
with thickening of the affected fascia, subfascial fluid collections

infection from soft tissue oedema and differentiating the extent

of osteomyelitis from reactive bone oedema can be difficult.8
Resolution of changes seen on MRI imaging lag behind therapeutic response to antibiotic treatment and can lead to unnecessary aggressive treatment. Another limitation of MRI is
imaging body areas with metallic orthopaedic hardware due to
artifacts.
MRI is also the modality of choice for evaluation of foot infections (for osteomyelitis and abscess) in diabetic patients, and
in spinal infections.
Diabetic osteomyelitis
Diabetic related pedal ulcers and osteomyelitis are associated
with high morbidity and healthcare costs. Diagnosis and management of diabetic pedal osteomyelitis require a multidisciplinary approach. A close working relationship between
orthopaedic surgeons, vascular surgeons, diabetic foot specialists
and radiologists is vital in these often complex cases. The majority of diabetic related foot infections arise from contiguous
spread from a foot ulcer.

Figure 10 MRI axial sequence of thighs e fluid sensitive fat suppressed sequence e demonstrating an abscess (pyomyositis) in right vastus lateralis
(white arrows) with surrounding muscle oedema (white arrow head).

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IMAGING

and extension of oedema into the intermuscular septa and

adjacent muscle.11
Pyomyositis can involve any muscle group in the body. S.
aureus is the most common pathogen but viruses, other bacteria,
fungi and parasites have all been implicated. One study emphasized the importance of concurrent diseases including diabetes,
HIV, chronic steroid usage, connective tissue disorders, history
of malignancy, and varied haematological disorders. These are
often present and further predispose individuals to the development of muscle infection.12 It is hypothesized that these systemic
processes, which result in varying degrees of immunosuppression, like local muscle trauma, make the muscle more susceptible
to infection by bacteria especially in the setting of transient
bacteraemia.13 Cases of pyomyositis have increased since the
emergence of HIV infection and in a study of North American
patients, 17% of patients with pyomyositis were HIV positive.14
Muscle infection is most often seen in young adults and only a
single muscle is affected, although multiple sites may be involved
in 11%e43% of patients with pyomyositis. The most common
site of infection is the quadriceps muscle, followed by the glutaeal and iliopsoas muscles, with upper extremity muscles being
affected less frequently.15 In the past, it was shown that iliopsoas
pyomyositis affected up to 20% of patients with spinal tuberculosis, so that the diagnosis of an iliopsoas abscess most
frequently implied an underlying tuberculous infection of the
spine. Today, however, iliopsoas pyomyositis most commonly
occurs secondary to gastrointestinal or urinary tract infections
(Figures 9e13).16

Figure 11 MRI right shoulder axial sequence e fluid sensitive fat suppressed e demonstrating abscess in the infraspinatus muscle (black arrows) with further oedema in posterior deltoid muscle.

Nuclear medicine e radionuclide imaging

This involves functional rather than anatomical assessment of
abnormalities in the bone, where the turnover increases in cases
of infection. It is a reasonable choice when MRI is not available
or contraindicated.

Figure 12 MRI lumbar spine sagittal STIR sequence with spondylodiscitis

from T10/11 to T12/L1 disc levels with abscess in the discs, oedema in the
vertebral bodies and near complete collapse of T12 vertebral body and
secondary angular kyphotic deformity centered at this level.

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Figure 13 MRI sagittal sequence of forearm and wrist demonstrating subperiosteal abscess (black arrows) at distal metaphysis of radius.

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IMAGING

Triple phase bone scintigraphy

Bone scintigraphy using technetium-99m-labelled diphosphonates
has an accuracy of only 50%e70%. A normal result essentially
excludes osteomyelitis with sensitivity greater than 90% when the
correlative radiograph is normal. Scintigraphy assesses the whole
body skeleton and can be particularly useful for multifocal infections. The accumulation of bone tracer depends on blood flow
and rate of new bone formation. This is however not specific for
osteomyelitis and may also be seen in fracture, tumour and treated
osteomyelitis. Further limitations include poor resolution and
lower specificity in the children and elderly.

infections. Each modality as discussed in the article has advantages and limitations and are often complementary to each
other. Therefore it is important to understand their principles
and use them based on the clinical indication, history and
availability.
A

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Gallium-67 and dual tracer scans

Gallium scans utilize the affinity of gallium-67 to acute phase
reactants (such as transferrin, lactoferrin) to demonstrate areas
of inflammation, which may be related to infection. The test is
helpful when findings are clearly positive or negative but findings are frequently equivocal making interpretation difficult.
Further disadvantages include the need for two isotopes and
imaging having to be performed over several days.
The addition of a Galliun-67 scan complements bone scintigraphy and improves the interpretation of both tests as compared
to either performed alone.
Targeted white cell scan
White blood cell (WBC) scans are considered superior to both
bone scintigraphy and gallium-67 scans in the assessment of
chronic osteomyelitis. WBC scans have a higher specificity in
infections of appendicular bones as compared to the axial skeleton due to false-positive uptake in the normal red bone marrow.
Complementing the examination with Tc-99m sulfur colloid scan
helps differentiate normal marrow from infection. Both labelled
leukocytes and sulfur colloid accumulate in the bone marrow,
but only labelled leukocytes accumulate in infection.17
Positron emission tomography (PET)
Increasing research is being carried out to assess the usefulness
of PET in osteomyelitis and the results have been encouraging.
The accuracy of PET in the diagnosis of musculoskeletal infections was 94 % compared with 81% for combined bone and
white blood cell scan.18 A recent meta-analysis found PET to be
the most accurate diagnostic modality for osteomyelitis. Its limitation of anatomical localization can be overcome by combining
it with CT. However there is currently limited availability of PET
and further dedicated investigations are needed for accurately
determining its role in musculoskeletal infections.

Conclusion
Imaging involves a wide range of modalities and plays a paramount role in the diagnosis and management of musculoskeletal

ORTHOPAEDICS AND TRAUMA --:-

2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bhat V, Gupta H, The radiological diagnosis of infection, Orthopaedics and Trauma (2014), http://dx.doi.org/
10.1016/j.mporth.2014.03.001