Infective Inflammatory Bone Disease

  • Klaus Bohndorf
  • Hassan Douis
Part of the Medical Radiology book series (MEDRAD)


Infectious inflammatory bone disease can develop via three routes: Hematogenous seeding, contiguous spread from an adjacent soft tissue or joint infection and direct implantation of microorganisms. A chronological view on osteomyelitis distinguishes acute, subacute and chronic osteomyelitis. The MR diagnosis of bone infection has to focus on (a) bone marrow inflammation, (low signal in T1, high signal in intermediate and T2-weighted TSE sequences, as well as in T1 with contrast), (b) intraosseous abscesses (similar to bone marrow inflammation but with a characteristic high signal rim in T1 with contrast), (c) sequestra (low signal in T1, low signal in intermediate and T2 and a peripheral enhancement in T1 with contrast), (d) cortical destruction (higher signal than bone in all sequences) and (e) sinus tracts into the peripheral soft tissues. In chronic post-traumatic osteomyelitis the same rules for diagnosis have to be applied, although extensive remodelling processes which include sclerosis, fibrosis and cortical thickening have to be taken into account. Sequestra and sinus tracts are regularly seen in active chronic osteomyelitis. Infections of the spine are divided into spondylitis, discitis, spondylodiscitis and spondylarthritis (septic arthritis of the facet joints) and mostly occur in the elderly. In the acute stage of the disease, spondylitis is characterised by increased signal intensity within the vertebral body in the water sensitive sequences and on the contrast-enhanced examination as well as decreased signal intensity on the T1-weighted spin echo sequence. Contrast-enhanced MRI is most sensitive in the identification of early vertebral infection. The infection typically begins at the antero-lateral aspect of the vertebral body and adjacent to the vertebral endplates. T1-weighted spin echo sequences depict the destruction of the vertebral endplates relatively well because the normal cortical signal void of the endplate changes to an intermediate signal. Disc involvement is seen early in spondylitis. T2-weighted spin echo sequences demonstrate increased signal intensity within the disc due to infection of the disc. The diagnosis of an abscess within the disc requires identification of signal intensity similar to fluid on T2-weighted spin echo sequences and lack of enhancement of this area on contrast-enhanced MRI. Osteomyelitis of the diabetic foot encounters special features based on the nature of the disease. In water sensitive sequences and after contrast an increased marrow signal is often seen in these patients and represents an unspecific finding. The diagnosis of osteomyelitis in diabetic foot has to rely mainly on the identification of an intraosseous abscess. Sinus tracts extending to bone, sequestrum formation and cortical destruction significantly help to build up a correct diagnosis.


Vertebral Body Septic Arthritis Bone Marrow Oedema Increase Signal Intensity Chronic Osteomyelitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We acknowledge the help of Dr Asif Saifuddin (Consultant Musculoskeletal Radiologist at The Royal National Orthopaedic Hospital, Stanmore, UK) who provided cases for illustration.


  1. Bamberger DM, Daus GP, Gerding DN (1987) Osteomyelitis in the feet of diabetic patients: long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med 83:653–660PubMedCrossRefGoogle Scholar
  2. Bitzer M, Schick F, Hartmann J, Geist-Barth B, Stern W, Krackhardt T, Seemann M, Morgalla M, Pereira P, Claussen CD (2002) MRT-Darstellung intraossärer Sequester und Fistelsysteme bei chronischer Osteomyelitis durch Standardsequenzen, hochselektive chemical-shift-Bildgebung, Diffusionsgewichtung and Magnetisierungstransfer. Fortschr Röntgenstr 174:1422–1429CrossRefGoogle Scholar
  3. Boden SD, Davis DO, Dina TS (1992) Postoperative diskitis: distinguishing early MR imaging findings from normal postoperative disk space changes. Radiology 184:765–771PubMedGoogle Scholar
  4. Bohndorf K (1996) Bildgebende Diagnostik der akuten and chronischen Osteomyelitis. Radiologe 36:786–794PubMedCrossRefGoogle Scholar
  5. Borgström PS, Ekberg O, Lasson A (1988) Radiography of pressure ulcers. Acta Radiol 29:581–584PubMedGoogle Scholar
  6. Boutin RD, Brossmann J, Sartoris DJ, Reilly D, Resnick D (1998) Update on imaging of orthopaeic infections. Orthop Clin North Am 29:41–66PubMedCrossRefGoogle Scholar
  7. Calderone RR, Larsen JM (1996) Overview and classification of spinal infections. Orthop Clin North Am 27:1–8PubMedGoogle Scholar
  8. Craig JG, Amin MB, Wu K, Eyler WR, van Holsbeeck MT, Bouffard JA, Shirazi K (1997) Osteomyelitis of the diabetic foot: MR imaging-pathologic correlation. Radiology 203:849–855PubMedGoogle Scholar
  9. Dagirmanjian A, Schils J, McHenry MC (1999) MR imaging of spinal infections. Magn Reson Imaging Clin N Am 7:525–538PubMedGoogle Scholar
  10. Dagirmanjian A, Schils J, McHenry M, Modic MT (1996) MR Imaging of vertebral osteomyelitis revisited. Am J Roentegnol 167:1539–1543Google Scholar
  11. Delling G (1997) Skelettsystem. In: Pathologie, Bd. 5. Remmele W (Hrsg.) Springer, Berlin S. 297–304Google Scholar
  12. Donovan A, Schweitzer ME (2010) Use of MR imaging in diagnosing diabetes-related pedal osteomyelitis. Radiographics 30(3):723–736PubMedCrossRefGoogle Scholar
  13. Epps CH Jr, Bryant DD 3rd, Coles MJ, Castro O (1991) Osteomyelitis in patients who have sickle-cell disease: Diagnosis and management. J Bone Joint Surg 73A:1281–1294Google Scholar
  14. Gillams AR, Chaddha B, Carter AP (1996) MR appearances of the temporal evolution and resolution of infectious spondylitis. Am J Roentgenol 166:903–907Google Scholar
  15. Glazer PA, Hu SS (1996) Pediatric spinal infections. Orthop Clin North Am 27:111–123PubMedGoogle Scholar
  16. Graif M, Schweitzer ME, Deely D, Mattencci T (1999) The septic versus nonseptic inflamed joint. Skeletal Radiol 28:616–620PubMedCrossRefGoogle Scholar
  17. Grey AC, Davies AM, Mangham DC, Grimer RJ, Ritchie DA (1998) The ‘penumbra sign’ on T1-weighted MR imaging in subacute osteomyelitis: Frequency, cause and significance. Clin Radiol 53(8):587–592PubMedCrossRefGoogle Scholar
  18. Haas DW, McAndrew MP (1996) Bacterial osteomyelitis in adults: evolving considerations in diagnosis and treatment. Am J Med 101:550–561PubMedCrossRefGoogle Scholar
  19. Harish S, Chiavaras MM, Kotnis N, REbello R (2011) MR imaging of skeletal soft tissue infection: utility of diffusion-weighted imaging in detecting abscess formation. Skeletal Radiol 40(3):285–294PubMedCrossRefGoogle Scholar
  20. Hopkins KL, Li KC, Bergman G (1995) Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol 24(5):325–330PubMedCrossRefGoogle Scholar
  21. Horowitz SH (1993) Diabetic neuropathy. Clin Orthop 296:78–85PubMedGoogle Scholar
  22. Jinkins JR, Bazan C 3rd, Xiong L (1996) MRI of disc protrusion engendered by infectious spondylitis. J Comp Assist Tomogr 20:715–718CrossRefGoogle Scholar
  23. Jones KM, Unger EC, Granstrom P, Seeger JF, Carmody RF, Yoshino M (1992) Bone marrow imaging using STIR at 0.5 and 1.5T. Magn Reson Imaging 10(2):169–176PubMedCrossRefGoogle Scholar
  24. Kaim A, Ledermann HP, Bongartz G, Messmer P, Mueller-Brand J, Steinbrich W (2000) Chronic posttraumatic osteomyelitis of the lower extremity: comparison of magnetic resonance imaging and combined bone scintigraphy/immunoscintrigraphy with radiolabelled monoclonal antigranulocyte antibodies. Skeletal Radiol 29:378–386PubMedCrossRefGoogle Scholar
  25. Kaim AH, Gross T, von Schulthess GK (2002) Imaging of chronic posttraumatic osteomyelitis. Eur Radiol 12:1193–1202PubMedCrossRefGoogle Scholar
  26. Kan JH, Young RS, Yu C, Hernanz-Schulman M (2010) Clinical impact of gadolinium in the MRI diagnosis of msuculoskeletal infection in children. Pediatr Radiol 40(7):1197–1205PubMedCrossRefGoogle Scholar
  27. Khan IA, Vaccaro AR, Zlotolow DA (1999) DA Management of vertebral diskitis and osteomyelitis. Orthopedics 22:758–765PubMedGoogle Scholar
  28. Khoo MM, Tyler PA, Saifuddin A, Padhani AR (2011) Diffusion-weighted imaging (DWI) in musculoskeletal MRI: a critical review. Skeletal Radiol 40(6):665–681PubMedCrossRefGoogle Scholar
  29. Kornaat PR, Cerlinck M, Vanhoenacker FM, De Praeter G, Kroon HM (2010) Brodie’s abscess revisited. JBR-BTR 93(2):81–86PubMedGoogle Scholar
  30. Küker W, Mull M, Mayfrank L, Topper R, Thron A (1997) Epidural spinal infection; variability of clinical and magnetic resonance imaging findings. Spine 22:544–551PubMedCrossRefGoogle Scholar
  31. Ledermann HP, Kaim A, Bongartz G, Steinbrich W (2000) Pitfalls and limitations of magnetic resonance imaging in chronic posttraumatic osteomyelitis. Eur Radiol 10:1815–1823PubMedCrossRefGoogle Scholar
  32. Ledermann HP, Morrison WB, Schweitzer ME (2002) Pedal abscesses in patients suspected of having pedal osteomyelitis: Analysis with MR imaging. Radiology 224:649–655PubMedCrossRefGoogle Scholar
  33. Milgram JW (1993) Osteomyelitis of the foot and ankle associated with diabetes mellitus. Clin Orthop 296:50–57PubMedGoogle Scholar
  34. Miller TT, Randolph DA Jr, Staron RB, Feldman F, Cushin S (1997) Fat-suppressed MRI of the musculoskeletal infection: Fast T2-weighted techniques versus gadolinium-enhanced T1-weighted images. Skeletal Radiol 26:654–658PubMedCrossRefGoogle Scholar
  35. Moore SL, Rafii M (2001) Imaging of musculoskeletal and spinal tuberculosis. Radiol Clin North Am 39:329–342PubMedCrossRefGoogle Scholar
  36. Moorthy S, Prabhu NK (2002) Spectrum of MR imaging findings in spinal tuberculosis. Am J Roentgenol 179:979–983Google Scholar
  37. Morrison WB, Schweitzer ME, Bock GW, Mitchell DG, Hume EL, Pathria MN, Resnick D (1993) Diagnosis of osteomyelitis: utility of fat-suppressed contrast-enhanced MR imaging. Radiology 189(1):251–257PubMedGoogle Scholar
  38. Munoz P, Bouza E (1999) Acute and chronic adult osteomyelitis and prothesis-related infections. Baillières Best Pract Res Clin Rheumatol 13(1):129–147PubMedCrossRefGoogle Scholar
  39. Nelson JD (1990) Acute osteomyelitis in children. Infect Dis Clin North Am 4(3):513–522PubMedGoogle Scholar
  40. Newman LG, Waller J, Palestro CJ, Schwartz M, Klein MJ, Herrmann G, Harrington E, Harrington M, Roman SH (1991) Unsuspected osteomyelitis and diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium-111 oxyquinoline. JAMA 266:1246–1251PubMedCrossRefGoogle Scholar
  41. Ozuna RM, Delamarter RB (1996) Pyogenic vertebral osteomyelitis and postsurgical disc space infections. Orthop Clin North Am 27:87–94PubMedGoogle Scholar
  42. Rodiek SO (2001) Bildgebende Verfahren bei spinalen Infektionen. Radiologe 41:976–986PubMedCrossRefGoogle Scholar
  43. Rothman SL (1996) The diagnosis of infections of the spine by modern imaging techniques. Orthop Clin North Am 27:15–31PubMedGoogle Scholar
  44. Sapico FL (1996) Microbiology and antimicrobial therapy of spinal infections. Orthop Clin North Am 27:9–13PubMedGoogle Scholar
  45. Staubach KH, Bruch HP, Sobach W (2000) Osteomyelitis. In: von Mare R, Mertens T, Trautmann M, Vanek E (Hrgs) Klinische Infektiologie, Urban and Fischer, München, pp 494–499Google Scholar
  46. Toledano TR, Fatone EA, Weis A, Cotton A, Beltran J (2011) MRI evaluation of bone marrow changes in the diabetic foot: a practical approach. Semin Musculoskelet Radiol. 15(3):257–268PubMedCrossRefGoogle Scholar
  47. Unal O, Koparan HI, Avcu S, Kalender AM, Kisli E (2011) The diagnostic value of diffusion-weighted magnetic resonance imaging in soft tissue abscesses. Eur J Radiol 77(3):490–494PubMedCrossRefGoogle Scholar
  48. Vaccaro A, Shah SH, Schweitzer ME, Rosenfeld JF, Cotler JM (1999) MRI description of vertebral osteomyelitis, neoplasm, and compression fracture. Orthopedics 22:67–73PubMedGoogle Scholar
  49. Varma R, Lander P, Assaf A (2001) Imaging of pyogenic infectious spondylodiskitis. Radiol Clin North Am 39:203–213PubMedCrossRefGoogle Scholar
  50. Weinstein D, Wang A, Chambers R, Stuart CA, Motz HA (1993) Evaluation of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections. Foot Ankle 14:18–22PubMedGoogle Scholar
  51. Wunsch R, Darge K, Rohrschneider W, Zieger B, Troger J (2001) Akute hämatogene Osteomyelitis – Ausschluss mit Turbo-STIR-Sequenz? Radiologe 41(5):439–441PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg  2013

Authors and Affiliations

  1. 1.Department of RadiologyKlinikum AugsburgAugsburgGermany
  2. 2.Royal National Orthopaedic Hospital NHS TrustStanmoreUK

Personalised recommendations