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Skeletal Radiology

, Volume 39, Issue 10, pp 957–971 | Cite as

Imaging of musculoskeletal soft tissue infections

  • Marcin B. Turecki
  • Mihra S. Taljanovic
  • Alana Y. Stubbs
  • Anna R. Graham
  • Dean A. Holden
  • Tim B. Hunter
  • Lee F. Rogers
Review Article

Abstract

Prompt and appropriate imaging work-up of the various musculoskeletal soft tissue infections aids early diagnosis and treatment and decreases the risk of complications resulting from misdiagnosis or delayed diagnosis. The signs and symptoms of musculoskeletal soft tissue infections can be nonspecific, making it clinically difficult to distinguish between disease processes and the extent of disease. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of soft tissue infections. Computed tomography (CT), ultrasound, radiography and nuclear medicine studies are considered ancillary. This manuscript illustrates representative images of superficial and deep soft tissue infections such as infectious cellulitis, superficial and deep fasciitis, including the necrotizing fasciitis, pyomyositis/soft tissue abscess, septic bursitis and tenosynovitis on different imaging modalities, with emphasis on MRI. Typical histopathologic findings of soft tissue infections are also presented. The imaging approach described in the manuscript is based on relevant literature and authors’ personal experience and everyday practice.

Keywords

Soft tissue infection Magnetic resonance imaging (MRI) Imaging 

References

  1. 1.
    Hadley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Phys. 2003;68:323–8.Google Scholar
  2. 2.
    McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558–63.PubMedCrossRefGoogle Scholar
  3. 3.
    Hill MK, Sanders CV. Necrotizing and gangrenous soft tissue infections. In: Sanders CV, Nesbitt Jr LT, editors. The skin and infection: a color atlas and text. Baltimore: Williams & Wilkins; 1995. pp. 62–75.Google Scholar
  4. 4.
    Bosshardt TL, Henderson VJ, Organ CH. Necrotizing soft-tissue infections. Arch Surg. 1996;131:846–52.PubMedGoogle Scholar
  5. 5.
    Chauhan S, Jain S, Varma S, Chauhan SS. Tropical Pyomoyositis (myositis tropicans): current perspective. Postgrad Med J 2004;80:267–70.PubMedCrossRefGoogle Scholar
  6. 6.
    Hill MK, Sanders CV. Skin and soft tissue infections in critical care. Crit Care Med. 1998;14:251–62.Google Scholar
  7. 7.
    Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE—Acute Physiology and Chronic Health Evaluation: a physiologically based classification system. Crit Care Med 1981;9:591–97.PubMedCrossRefGoogle Scholar
  8. 8.
    Dellinger EP, Wertz MJ, Meakins JL, Solomkin JS, Allo MD, Howard RJ, et al. Surgical Infection Stratification System for intra-abdominal infection. Multicenter trial. Arch Surg 1985;120:21–29.PubMedGoogle Scholar
  9. 9.
    Pessa ME, Howard RJ. Necrotizing fasciitis. Surg Gynecol Obstet. 1985;161:357–61.PubMedGoogle Scholar
  10. 10.
    Elliott D, Kufera JA, Myers RA. The microbiology of necrotizing soft tissue infections. Am J Surg. 2000;179:361–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Beltran J, Noto AM, McGhee RB, Freedy RM, McCalla MS. Infections of the musculoskeletal system: high-field-strength MR imaging. Radiology 1987;164(2):449–54.PubMedGoogle Scholar
  12. 12.
    Brothers TE, Tagge DU, Stutley JE, Conway WF, Schutte HD Jr, Byrne TK. Magnetic resonance imaging differences between necrotizing and non-necrotizing fasciitis of the lower extremity. J Am Coll Surg. 1998;187:416–21.PubMedCrossRefGoogle Scholar
  13. 13.
    Beltran J. MR imaging of soft tissue infection. Magn Reson Imaging Clin N Am. 1995;3:743–51.PubMedGoogle Scholar
  14. 14.
    Beauchamp NJ, Scott WW, Gottlieb LM, Fishman EK. CT evaluation of soft tissue and muscle infection and inflammation: a systematic compartmental approach. Skel Rad 1995;24:317–24.PubMedCrossRefGoogle Scholar
  15. 15.
    Vukanovic S, Hauser H, Wettstein P. CT localization of myonecrosis for surgical decompression. AJR Am J Roentgenol. 1980;135:1298.PubMedGoogle Scholar
  16. 16.
    Pretorius ES, Fishman EK. Helical CT of musculoskeletal infection. Crit Rev Diagn Imaging. 2001;42:259–305.PubMedGoogle Scholar
  17. 17.
    Wysoki MG, Santora TA, Shah RM, Friedman AC. Necrotizing fasciitis: CT characterstics. Radiology 1997;203(3):859–63Google Scholar
  18. 18.
    Ma LD, Frassica FJ, Bluemke DA, Fishman EK. CT and MRI evaluation of musculoskeletal infection. Crit Rev Diagn Im 1997;36(4):535–68.Google Scholar
  19. 19.
    Struk DW, Munk PL, Lee MJ, Ho SG, Worsley DF. Imaging of soft tissue infections. Radiol Clin North Am. 2001;39:277–303.PubMedCrossRefGoogle Scholar
  20. 20.
    Gordon BA, Martinez S, Collins AJ. Pyomyositis: characteristics at CT and MR imaging. Radiology. 1995;197:279–86.PubMedGoogle Scholar
  21. 21.
    Buckwalter KA. Optimizing imaging techniques in the postoperative patient. Semin Musculoskelet Radiol. 2007;11:261–72.PubMedCrossRefGoogle Scholar
  22. 22.
    Lee MJ, Kim S, Lee SA, Song HT, Huh YM, Kim DH et al. Overcoming artifacts from metallic orthopedic implants at high-field-strength MR imaging and multi-detector CT. Radiographics. 2007;27(3):791–803.PubMedCrossRefGoogle Scholar
  23. 23.
    Kay J. Nephrogenic systemic fibrosis: a gadolinium-associated fibrosing disorder in patients with renal dysfunction. Ann Rheum Dis. 2008;67(Suppl 3):66–9.CrossRefGoogle Scholar
  24. 24.
    Thomsen HS, Marckmann P, Logager VB. Update on nephrogenic systemic fibrosis. Magn Reson Imaging Clin N Am. 2008;16:551–60.PubMedCrossRefGoogle Scholar
  25. 25.
    Van der Molen AJ. Nephrogenic systemic fibrosis and the role of gadolinium contrast media. J Med Imaging Radiat Oncol. 2008;52:339–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Shellock FG, Spinazzi A. MRI safety update 2008: part 1, MRI contrast agents and nephrogenic systemic fibrosis. AJR Am J Roentgenol. 2008;191:1129–39.PubMedCrossRefGoogle Scholar
  27. 27.
    Chau CL, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol. 2005;60:149–59.PubMedCrossRefGoogle Scholar
  28. 28.
    Cardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in musculoskeletal infections. Radiol Clin North Am. 2001;39:191–201.PubMedCrossRefGoogle Scholar
  29. 29.
    Bureau NJ, Ali SS, Chhem RK, Cardinal E. Ultrasound of musculoskeletal infections. Semin Musculoskelet Radiol. 1998;2:299–306.PubMedCrossRefGoogle Scholar
  30. 30.
    Jacobson JA, Powell A, Craig JG, Bouffard JA, van Holsbeeck MT. Wooden foreign bodies in soft tissue: detection at US. Radiology. 1998;206:45–8.PubMedGoogle Scholar
  31. 31.
    Leung A, Patton A, Navoy J, Cummings RJ. Intra-operative sonography-guided removal of radiolucent foreign bodies. J Pediatr Orthop. 1998;18:259–61.PubMedCrossRefGoogle Scholar
  32. 32.
    Vartan MV, Karchmer AW, Glurini JM, Rosenthal DI. Is there a role for imaging in the management of patients with diabetic foot? Skel Rad 2009;38:633–36.CrossRefGoogle Scholar
  33. 33.
    Crymes WB, Demos H, Gordon L. Detection of musculoskeletal infection with 18F-FDG PET: review of the current literature. J Nucl Med Technol. 2004;32:12–5.PubMedGoogle Scholar
  34. 34.
    De Winter F, Vogelaers D, Gemmel F, Dierckx RA. Promising role of 18-F-fluoro-D-deoxyglucose positron emission tomography in clinical infectious diseases. Eur J Clin Microbiol Infect Dis. 2002;21(4):247–57.PubMedCrossRefGoogle Scholar
  35. 35.
    Mettler FA, Guiberteau MJ. Inflammation and infection imaging. In: Essentials of nuclear medicine imaging. 5th ed. Philadelphia, PA: Saunders Elsevier; 2006. pp. 341–358Google Scholar
  36. 36.
    Kothari NA, Pelchovitz DJ, Meyer JS. Imaging of musculoskeletal infections. Radiol Clin North Am. 2001;39:653–71.PubMedCrossRefGoogle Scholar
  37. 37.
    Swartz MN. Cellulitis. N Engl J Med. 2004;350:904–12.PubMedCrossRefGoogle Scholar
  38. 38.
    Struk DW, Munk PL, Lee MJ, Ho SG, Worsley DF. Imaging of soft tissue infections. Radiol Clin North Am. 2001;39:277–303.PubMedCrossRefGoogle Scholar
  39. 39.
    Towers JD. The use of intravenous contrast in MRI of extremity infection. Semin Ultrasound CT MR. 1997;18:269–75.PubMedCrossRefGoogle Scholar
  40. 40.
    Gylys-Morin VM. MR imaging of pediatric musculoskeletal inflammatory and infectious disorders. Magn Reson Imaging Clin N Am. 1998;6:537–59.PubMedGoogle Scholar
  41. 41.
    Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR 1996;166:149–52.PubMedGoogle Scholar
  42. 42.
    Arslan H, Sakarya ME, Bozkurt M, Unal O, Dilek ON, Harman M. The role of power Doppler sonography in the evaluation of superficial soft tissue abscesses. Eur J Ultrasound 1998;8:101–06.PubMedCrossRefGoogle Scholar
  43. 43.
    Hook EW. Acute cellulitis. Arch Dermatol. 1987;123:460.PubMedCrossRefGoogle Scholar
  44. 44.
    Schweitzer ME, Morrison WB. MR imaging of the diabetic foot. Radiol Clin North Am. 2004;42:61–71.PubMedCrossRefGoogle Scholar
  45. 45.
    Palestro CJ, Torres MA. Radionuclide imaging of nonosseous infection. Q J Nucl Med. 1999;43:46–60.PubMedGoogle Scholar
  46. 46.
    Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of literature. J Am Coll Surg 2009;208:279–88.PubMedCrossRefGoogle Scholar
  47. 47.
    Urschel JD. Classic diseases revisited: necrotizing soft tissue infections. Postgrad Med J. 1999;75:645–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Janevicius RV, Hann SE, Batt MD. Necrotizing fasciitis. Surg Gynecol Obstet. 1982;154:97–102.PubMedGoogle Scholar
  49. 49.
    Fugitt JB, Puckett ML, Quigley MM, Kerr SM. Necrotizing fasciitis. Radiographics 2004;24(5):1472–76.PubMedCrossRefGoogle Scholar
  50. 50.
    Schmid M, Kossman T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol. 1998;170:615.PubMedGoogle Scholar
  51. 51.
    Farahani K, Sinha U, Sinha S, Chiu LC, Lufkin RB. Effect of field strength on susceptibility artifacts in magnetic resonance imaging. Comput Med Imaging Graph. 1990;14(6):409–13.PubMedCrossRefGoogle Scholar
  52. 52.
    Janzig HJM, Broos PLO. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment. Injury. 2001;32:415–21.CrossRefGoogle Scholar
  53. 53.
    Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg. 2002;89:397–412.PubMedCrossRefGoogle Scholar
  54. 54.
    Whitesides TE Jr, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop. 1975;113:43–51.PubMedCrossRefGoogle Scholar
  55. 55.
    McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. J Bone Joint Surg Br. 1996;78:99–104.PubMedGoogle Scholar
  56. 56.
    Williams PR, Russell ID, Mintowt-Czyz WJ. Compartment pressure monitoring current UK orthopaedic practice. Injury. 1998;29:229–32.PubMedCrossRefGoogle Scholar
  57. 57.
    Chao H, Kong M, Lin T. Diagnosis of necrotizing fasciitis in children. J Ultrasound Med. 1999;18:277.PubMedGoogle Scholar
  58. 58.
    Kaiser RE, Cerra FB. Progressive necrotizing surgical infections—a unified approach. J Trauma. 1981;21:349–55.PubMedCrossRefGoogle Scholar
  59. 59.
    Majeski JA, Alexander JW. Early diagnosis, nutritional support and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg. 1983;145:784–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990;108:847–50.PubMedGoogle Scholar
  61. 61.
    Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990’s. Cleve Clin J Med. 1992;59:517–28.PubMedGoogle Scholar
  62. 62.
    Rodgers WB, Yodlowski ML, Mintzer CM. Pyomyositis in patients who have human immunodeficiency virus. J Bone Joint Surg Am. 1993;75:588.PubMedGoogle Scholar
  63. 63.
    Miyake H. Beitrage zur kenntnis der sogenenten myositis infectiosa. Mitt Grenzgeb Med Chir. 1904;13:155.Google Scholar
  64. 64.
    Trusen A, Beissert M, Schultz G, Chittka B, Darge K. Ultrasound and MRI features of pyomyositis in children. Eur Radiol 2003;13:1050–55.PubMedGoogle Scholar
  65. 65.
    Tomona L, Madariaga MG: Tropical Pyomyositis In A Temperate Region. The Internet J Infect Dis. 2005;4:2.Google Scholar
  66. 66.
    Pretorius ES, Hruban RH, Fishman EK. Tropical pyomyositis: imaging findings and a review of the literature. Skeletal Radiol. 1996;25:576–9.PubMedCrossRefGoogle Scholar
  67. 67.
    Hopkins K, Li K, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious process. Skeletal Radiol. 1995;24:325–30.PubMedCrossRefGoogle Scholar
  68. 68.
    Mazur JM, Ross G, Cummings J, Hahn GA, McCluskey WP. Usefulness of magnetic resonance imaging for the diagnosis of acute musculoskeletal infection in children. J Ped Orthop 1995;15:144–47.Google Scholar
  69. 69.
    Saiag P, Le Breton C, Pavlovic M, Fouchard N, Delzant G, Bigot JM. Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis. Arch Dermatol 1994;130:1150–1158.PubMedCrossRefGoogle Scholar
  70. 70.
    Manaster BJ, May DA, Disler DG. Musculoskeletal imaging—the requisites. 3rd ed. Mosby 2007;2:38–39.Google Scholar
  71. 71.
    Gordon BA, Martinez S, Collins AJ. Pyomyositis: characteristics at CT and MR imaging. Radiology. 1995;197:279–86.PubMedGoogle Scholar
  72. 72.
    Bureau NJ, Chhem RK, Cardinal E. Musculoskeletal infections: US manifestations. Radiographics. 1999;19:1585–92.PubMedGoogle Scholar
  73. 73.
    Craig JG. Infection: Ultrasound-guided procedures. Radiol Clin North Am. 1999;37:669–78.PubMedCrossRefGoogle Scholar
  74. 74.
    Loyer EM, Kaur H, David CL, DuBrow R, Eftekhari FM. Importance of dynamic assessment of the soft tissues in the sonographic diagnosis of echogenic superficial abscesses. J Ultras Med 1995;14:665–68.Google Scholar
  75. 75.
    Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005;19:991–1005.PubMedCrossRefGoogle Scholar
  76. 76.
    Lee EY, Rubin DA, Brown DM. Recurrent Mycobacterium marinum tenosynovitis of the wrist mimicking extraarticular synovial chondromatosis on MR images. Skeletal Radiol. 2004;33:405–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am. 1992;23:171–85.PubMedGoogle Scholar
  78. 78.
    Newman ED, Harrington TM, Torretti D, Bush DC. Suppurative extensor tenosynovitis caused by Staphylococcus aureus. J Hand Surg [Am] 1989;14(5):849–51.CrossRefGoogle Scholar
  79. 79.
    Chang E, Talbot-Stern J. Bursitis. e-Medicine 2008.Google Scholar
  80. 80.
    Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum. 1995;24:391–410.PubMedCrossRefGoogle Scholar
  81. 81.
    Yoshida S, Shidoh M, Imai K, Imai A, Konishi Y, Kon S. Rice bodies in ischiogluteal bursitis. Postgrad Med J. 2003;930:220–21.CrossRefGoogle Scholar
  82. 82.
    Rutten MJ, van den Berg JC, van den Hoogen FH, Lemmens JA. Nontuberculous mycobacterial bursitis and arthritis of the shoulder. Skeletal Radiol. 1998;27:33–35PubMedCrossRefGoogle Scholar
  83. 83.
    Costantino TG, Roemer B, Leber EH. Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis. J Emerg Med. 2007;32:295–7.PubMedCrossRefGoogle Scholar
  84. 84.
    Slawski DP, Howard RF. Surgical management of refractory trochanteric bursitis. Am J Sports Med. 1997;25:86–9.PubMedCrossRefGoogle Scholar
  85. 85.
    Laupland KB, Davies HD. Olecranon septic bursitis managed in an ambulatory setting. Clin Invest Med. 2001;24:171–8.PubMedGoogle Scholar

Copyright information

© ISS 2009

Authors and Affiliations

  • Marcin B. Turecki
    • 1
  • Mihra S. Taljanovic
    • 1
  • Alana Y. Stubbs
    • 2
  • Anna R. Graham
    • 3
  • Dean A. Holden
    • 1
  • Tim B. Hunter
    • 1
  • Lee F. Rogers
    • 1
  1. 1.Department of RadiologyUniversity of Arizona HSCTucsonUSA
  2. 2.Department of RadiologySouthern Arizona VA Health Care SystemTucsonUSA
  3. 3.Department of PathologyUniversity of Arizona HSCTucsonUSA

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