Imaging of Musculoskeletal Disorders
Osteomyelitis

Key points

  • Osteomyelitis has aggressive features which may be similar to the appearance of tumours
  • Infection to bone is usually direct – via the skin
  • Diabetes is the main risk factor
  • Always mention the anatomical location of a skin ulcer when requesting imaging to look for osteomyelitis

Infection of bone (osteomyelitis) usually arises directly via skin ulceration, infection of underlying subcutaneous soft tissues, and extension of infection down into a bone. Osteomyelitis only occasionally arises from infection spread haematogenously.

Skin ulcers are not always visible on an X-ray, so it is important to state the exact location of a skin ulcer whenever requesting imaging to look for osteomyelitis. Risk factors include diabetes and any form of immunosuppression.

Heel ulcer and osteomyelitis

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Heel ulcer and osteomyelitis

  • The skin and subcutaneous soft tissue are deficient at the site of a skin ulcer
  • Infection has passed down to the bone surface of calcaneus which is eroded

Osteomyelitis in diabetes

Diabetes is the main risk factor for osteomyelitis and the foot is most commonly affected.

Osteomyelitis in diabetic foot - 1

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Osteomyelitis in diabetic foot - 1

  • There is no definite abnormality of bone seen on the foot X-ray of this diabetic patient with clinically suspected osteomyelitis
  • There was a skin ulcer near the 1st metatarsal head
  • The skin ulcer is not visible on the X-ray – as is often the case
  • Bone density of the 1st metatarsal head is normal
  • The initial X-ray in osteomyelitis is typically normal

Osteomyelitis in diabetic - 2

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Osteomyelitis in diabetic - 2

  • Despite antibiotic treatment, just a few weeks later, changes of osteomyelitis have become visible
  • Bone density is reduced in the 1st metatarsal head and the adjacent proximal phalanx
  • The 1st metatarsal bone is shortened due to a pathological fracture of the 1st metatarsal head

Osteomyelitis in diabetic - 3

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Osteomyelitis in diabetic - 3

  • A decision was made to amputate the first toe at the mid-point of the metatarsal – a common consequence of osteomyelitis of the foot in diabetics

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Page edited by: Dr Richard Smith BSc MSc MBBS FRCP PGDip - Consultant Rheumatologist (Read bio)

Last reviewed: January 2020