Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Approach to imaging modalities in the setting of suspected osteomyelitis

Charles E Spritzer, MD
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Radiographic imaging is useful for confirming or excluding the diagnosis of osteomyelitis, delineating the extent of disease, and planning therapy (table 1). Imaging findings must be interpreted in clinical context [1]. Osteomyelitis may occur in any bone; the largest body of data on imaging modalities for evaluation of osteomyelitis comes from the literature on diabetic foot infections.

The benefits and limitations of plain radiographs, magnetic resonance imaging, computed tomography, nuclear modalities, and ultrasonography for the diagnosis of osteomyelitis will be reviewed here. An integrated diagnostic approach to evaluation of adults with suspected osteomyelitis is presented in detail separately. (See "Overview of osteomyelitis in adults", section on 'Clinical approach'.)


Osteomyelitis can occur as a result of hematogenous seeding, contiguous spread of infection to bone from adjacent soft tissues and joints, or direct inoculation of infection into the bone as a result of trauma or surgery. The most commonly affected adults are poorly controlled diabetics with peripheral neuropathy and vascular insufficiency [2]. (See "Overview of osteomyelitis in adults", section on 'Pathophysiology'.)

In the setting of osteomyelitis, inflammatory exudate in the marrow causes elevated medullary pressure, which compresses vascular channels, leading to ischemia and bone necrosis. If the areas of necrotic bone separate from the remaining viable bone, sequestra are formed. Surviving bone and periosteum ultimately produce a sheath of bone surrounding the area of necrosis, which is referred to as an involucrum. Both the sequestra and involucrum may be apparent radiographically (image 1 and image 2) [2].

Acute osteomyelitis refers to infection in the bone prior to development of sequestra, usually measured in days or weeks. In some forms of osteomyelitis, development of sequestra is relatively slow (such as vertebral osteomyelitis), while in others the development of sequestra occurs relatively rapidly (such as osteomyelitis in the setting of prosthetic devices or compound fractures) [1].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jun 8, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Pineda C, Vargas A, Rodríguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am 2006; 20:789.
  2. Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364:369.
  3. Harmer JL, Pickard J, Stinchcombe SJ. The role of diagnostic imaging in the evaluation of suspected osteomyelitis in the foot: a critical review. Foot (Edinb) 2011; 21:149.
  4. Centre for Clinical Practice at NICE (UK). Diabetic Foot Problems: Inpatient Management of Diabetic Foot Problems, National Institute for Health and Clinical Excellence, London 2011.
  5. Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis 2008; 47:519.
  6. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004; 39:885.
  7. Darouiche RO, Landon GC, Klima M, et al. Osteomyelitis associated with pressure sores. Arch Intern Med 1994; 154:753.
  8. Gold RH, Hawkins RA, Katz RD. Bacterial osteomyelitis: findings on plain radiography, CT, MR, and scintigraphy. AJR Am J Roentgenol 1991; 157:365.
  9. Bone and Joint Imaging, 3rd ed, Resnick D, Kransdorf M (Eds), Elsevier, Philadelphia 2005. p.718.
  10. Berbari EF, Steckelberg JM, Osmon DR. Osteomyelitis. In: Principles and Practice of Infectious Diseases, 6th ed, Mandell GL, et al (Eds), Elsevier, Philadelphia 2005. p.1322.
  11. Kaim AH, Gross T, von Schulthess GK. Imaging of chronic posttraumatic osteomyelitis. Eur Radiol 2002; 12:1193.
  12. Erdman WA, Tamburro F, Jayson HT, et al. Osteomyelitis: characteristics and pitfalls of diagnosis with MR imaging. Radiology 1991; 180:533.
  13. Durham JR, Lukens ML, Campanini DS, et al. Impact of magnetic resonance imaging on the management of diabetic foot infections. Am J Surg 1991; 162:150.
  14. Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008; 299:806.
  15. Kapoor A, Page S, Lavalley M, et al. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. Arch Intern Med 2007; 167:125.
  16. American College of Radiology. ACR Appropriateness Criteria. ACR 2012.
  17. Treglia G, Sadeghi R, Annunziata S, et al. Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: a systematic review and a meta-analysis. Foot (Edinb) 2013; 23:140.
  18. Demirev A, Weijers R, Geurts J, et al. Comparison of [18 F]FDG PET/CT and MRI in the diagnosis of active osteomyelitis. Skeletal Radiol 2014; 43:665.
  19. Tomas MB, Patel M, Marwin SE, Palestro CJ. The diabetic foot. Br J Radiol 2000; 73:443.
  20. Ahmadi ME, Morrison WB, Carrino JA, et al. Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics. Radiology 2006; 238:622.
  21. Karchevsky M, Schweitzer ME, Morrison WB, Parellada JA. MRI findings of septic arthritis and associated osteomyelitis in adults. AJR Am J Roentgenol 2004; 182:119.
  22. Dagirmanjian A, Schils J, McHenry M, Modic MT. MR imaging of vertebral osteomyelitis revisited. AJR Am J Roentgenol 1996; 167:1539.
  23. Dunbar JA, Sandoe JA, Rao AS, et al. The MRI appearances of early vertebral osteomyelitis and discitis. Clin Radiol 2010; 65:974.
  24. Ledermann HP, Kaim A, Bongartz G, Steinbrich W. Pitfalls and limitations of magnetic resonance imaging in chronic posttraumatic osteomyelitis. Eur Radiol 2000; 10:1815.
  25. Mader JT, Ortiz M, Calhoun JH. Update on the diagnosis and management of osteomyelitis. Clin Podiatr Med Surg 1996; 13:701.
  26. Wing VW, Jeffrey RB Jr, Federle MP, et al. Chronic osteomyelitis examined by CT. Radiology 1985; 154:171.
  27. Seltzer SE. Value of computed tomography in planning medical and surgical treatment of chronic osteomyelitis. J Comput Assist Tomogr 1984; 8:482.
  28. Gross T, Kaim AH, Regazzoni P, Widmer AF. Current concepts in posttraumatic osteomyelitis: a diagnostic challenge with new imaging options. J Trauma 2002; 52:1210.
  29. Al-Sheikh W, Sfakianakis GN, Mnaymneh W, et al. Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography. Radiology 1985; 155:501.
  30. Kaim A, Maurer T, Ochsner P, et al. Chronic complicated osteomyelitis of the appendicular skeleton: diagnosis with technetium-99m labelled monoclonal antigranulocyte antibody-immunoscintigraphy. Eur J Nucl Med 1997; 24:732.
  31. Kolindou A, Liu Y, Ozker K, et al. In-111 WBC imaging of osteomyelitis in patients with underlying bone scan abnormalities. Clin Nucl Med 1996; 21:183.
  32. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR Am J Roentgenol 1992; 158:9.
  33. Schauwecker DS. Osteomyelitis: diagnosis with In-111-labeled leukocytes. Radiology 1989; 171:141.
  34. Heiba SI, Kolker D, Mocherla B, et al. The optimized evaluation of diabetic foot infection by dual isotope SPECT/CT imaging protocol. J Foot Ankle Surg 2010; 49:529.
  35. Keidar Z, Militianu D, Melamed E, et al. The diabetic foot: initial experience with 18F-FDG PET/CT. J Nucl Med 2005; 46:444.
  36. Chacko TK, Zhuang H, Nakhoda KZ, et al. Applications of fluorodeoxyglucose positron emission tomography in the diagnosis of infection. Nucl Med Commun 2003; 24:615.
  37. Wang GL, Zhao K, Liu ZF, et al. A meta-analysis of fluorodeoxyglucose-positron emission tomography versus scintigraphy in the evaluation of suspected osteomyelitis. Nucl Med Commun 2011; 32:1134.
  38. Palestro CJ. Radionuclide imaging of osteomyelitis. Semin Nucl Med 2015; 45:32.
  39. Basu S, Chryssikos T, Houseni M, et al. Potential role of FDG PET in the setting of diabetic neuro-osteoarthropathy: can it differentiate uncomplicated Charcot's neuroarthropathy from osteomyelitis and soft-tissue infection? Nucl Med Commun 2007; 28:465.
  40. Gratz S, Dörner J, Fischer U, et al. 18F-FDG hybrid PET in patients with suspected spondylitis. Eur J Nucl Med Mol Imaging 2002; 29:516.
  41. Schauwecker DS. The role of nuclear medicine in osteomyelitis. In: Skeletal Nuclear Medicine, Collier DB, et al (Eds), Mosby, St. Louis 1996.
  42. Thrall J, Ziessman H. Nuclear Medicine: The Requisites, 2nd ed, Mosby, St. Louis 2001.
  43. Palestro CJ, Kim CK, Swyer AJ, et al. Radionuclide diagnosis of vertebral osteomyelitis: indium-111-leukocyte and technetium-99m-methylene diphosphonate bone scintigraphy. J Nucl Med 1991; 32:1861.
  44. Tumeh SS, Aliabadi P, Weissman BN, McNeil BJ. Chronic osteomyelitis: bone and gallium scan patterns associated with active disease. Radiology 1986; 158:685.
  45. Saha S, Burke C, Desai A, et al. SPECT-CT: applications in musculoskeletal radiology. Br J Radiol 2013; 86:20120519.
  46. Abiri MM, Kirpekar M, Ablow RC. Osteomyelitis: detection with US. Radiology 1989; 172:509.
  47. Howard CB, Einhorn M, Dagan R, Nyska M. Ultrasound in diagnosis and management of acute haematogenous osteomyelitis in children. J Bone Joint Surg Br 1993; 75:79.
  48. Wheat J. Diagnostic strategies in osteomyelitis. Am J Med 1985; 78:218.
  49. Booz MM, Hariharan V, Aradi AJ, Malki AA. The value of ultrasound and aspiration in differentiating vaso-occlusive crisis and osteomyelitis in sickle cell disease patients. Clin Radiol 1999; 54:636.