bone and joint infections (and mimics) - amazon web...
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© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Bone and Joint Infections (andMimics)
C. Craig Blackmore, MD, MPH, FASERVirginia Mason Medical Center
Seattle, WA
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Bone and Joint Infections
• Continuous infection (90%)§ Diabetics§ Trauma§ Iatrogenic
• Hematogenous spread§ Children, elderly§ Immunocompromise, systemic infection§ Intravenous drug use§ MRSA
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Osteomyelitis
• Risk factors§ Diabetes RR=5§Male RR=2§ Vascular disease RR=2
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Osteomyelitis
Involucrum
Sequestrum
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Direct Osteomyelitis
• Wounds• Decubitus Ulcers• Diabetic feet
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Osteomyelitis• Radiographs/CT§ Normal up to 2 weeks§ Focal osteopenia§ Periosteal new bone formation§ Bone destruction
• MRI§ High STIR signal, edema§ Low T1§ Enhancement
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Osteomyelitis
2 weeks later
STIRT1
T1
T1 Gad
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Hallux OsteomyelitisT1 Gad
T1 Gad
STIR
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Infected Arthroplasty• Radiographs often normal• Subtle (if any) lucencies• Periarticular new bone• Hip/shoulder 1%• Knee 2%
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Nuclear Medicine
Courtesy of Paul Sicuro, MD
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Pressure Ulcer
• Continued pressure/shear• Elderly, immobile, malnourished• Deep tissues more susceptible than skin§ Underestimate extent of injury
• Bony prominence§ Ischial tuberosity, sacrum, heel, elbow
• Imaging-extent of injury, infection
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Decubitus Ulcer
• Damage to skin and underlying tissue fromrestricted blood flow due to pressure
• Grade I-IV• Grade IV muscle and bone• Imaging to stage
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Decubitus Ulcer
10 months later
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Diabetic Osteomyelitis• 45 yo diabetic male with 1 year non-healing ulcer
STIR
T1 Gad
T1
T1
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Diabetic Foot:Accuracy of Imaging
ImagingModality
Source Number ofpatients
Sensitivity(%)
Specificity(%)
Radiography 4 trials 177 54 68
MRI 4 trials 135 90 79
Bone scan 6 trials 185 81 28
Probe tobone
2 trials 288 60 91
Dinh, et al. Clin Infect Dis 2008;299:806-813
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Diabetic FootSTIR
T1 GadT1 Gad
T1
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Diabetic Foot InfectionsT1 Gad
T1 GadT1
T1
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Bone Infarct
T1 Gad
T1 Gad
T1
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Bone Marrow Replacement
62 year old male with leukemia
PD Fat SatT1
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Septic Arthritis
• Direct inoculation§ Continuous infection§ Iatrogenic
• Risk factors§ Immunocompromise§ IVDA§ Rheumatoid arthritis§ Diabetes
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Septic Arthritis63 yr old female 3 weeks
post prolotherapy
STIR
T1 Gad
T1 Gad
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Radiograph Findings
• Early Normal§ Joint effusion§ Osteopenia
• Late§ Focal bone loss§ Bare area erosions§ Collapse subchondral bone
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Septic Arthritis
• Imaging (x-ray, CT) NOT sensitive to earlyseptic arthritis
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MRI Findings-T1
Low T1 in peri-articular boneConfluent low T1 implies osteomyelitis
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MRI Findings-T2/STIR• Joint effusion• High T2 in adjacent bone and soft tissues• Peri-articular bare areas
STIR
T2 Fat Sat
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MRI Findings-Contrast
• Thick synovial enhancement• Bare area enhancement
T1 GadT1 Gad
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Septic Athritis
62 yr old male, s/p bone marrowtransplant for lymphoma
T1 Gad
T1 Gad
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Osteomyelitis-Septic ArhtritisT1
T1
STIR
STIR
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SynovialChondromatosis/Septic Joint
STIR
T1 GadT1 Gad
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RheumatoidArthritis
STIR
T1 Gad
T1 Gad
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HemophiliaPD Fat Sat
PD Fat Sat
T2 GRE
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Pigmented Villonodular SynovitisPD Fat SatPD Fat Sat
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Charcot Joint• Disorganization/subluxation• Fragmentation• NO low T1 in bone• NO enhancement in bone
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Charcot vs Osteomyelitis
STIR
T1 Gad
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GoutSTIR T1 Gad
T1 Gad
T1 T1 Fat Sat
• Bare area erosions• Overhanging edges• Tophus• NO low T1 in bone