EARLY ROENTGEN OBSERVATIONS IN
ACUTE OSTEOMYELITIS
By MARIE A. CAPITANIO, M.D., and JOHN A. KIRKPATRICK, M.D.
PHILADELPHIA, PENNSYLVANIA
H EMATOGENEOUS osteomyelitis
continues to be endemic in pediatric
age group. The advent of antibiotics has
provided a means for cure but therapy must
be instituted early to be effective and to
prevent serious complications of
osteomyelitis. Early diagnosis is therefore
of paramount importance. When the classic
signs and symptoms of acute osteomyelitis
are present (i.e., local pain, swelling, heat
and tenderness, fever, and leucocytosis) the
diagnosis may be made by the clinician
without difficulty. However, since the
introduction of antibiotics there has been an
apparent change in the character of
osteomyelitis.2 this is manifest by an
increasing number of patients presenting
with a mild or subacute illness with an
insidious onset of symptoms and frequently
no associated systemic reaction. It is
difficult to make the diagnosis of
osteomyelitis in these patients on clinical
evidence alone, and other means for early
diagnosis are necessary. The changes that
can be appreciated roentgenographically in
the early stages of osteomyelitis, befora
there is visible bone destruction, are of
considerable assistance in making the earlt
diagnosis.
PATHOLOGY
Hematogeneus osteomyelitis is an
inflammatory process that begins in the
bone marrow. Almost without exception
the primary site of involvement is at the
ends of the long bones where growth is
most rapid. The rich blood supply and the
nature of the structure of the vessels at the
metaphysis, end-arteries, predispose to the
Lodgement of bacteria within the vessels in
this region. Once the nidus of onfection is
established, an integrated series of events
may take place if not interrupted by body
defences or altered by therapeutic
measures. Initially there is an increase in
the rate of blood flow to the region with an
associated arteriolar dilatation. Capillary
dilatation and increased capillary
permeability then ensue with a subsequent
outpouring of fluid from the capillaries into
the surrounding tissues. There is eventual
slowing or statis of the blood flow followed
by the appearance of white blood cells into
the inflammatory focus. The suppurative
process results in local destruction of
trabeculae and eventually, if unabated, may
spread throughout the intramedullary canal
producing widespread destruction of
trabeculae. The pus accumulating under
pressure in the intramedullary canal may
rupture through the cortex via multiple
sinus tracts and elevate the periosteum.
Chronic osteomyelitis is established at that
point. During the destructive phase cortical
bone may become devitalized and result in
the formation of sequestra. An involucrum
is formed when bone is produced by the
elevated periosteum. Rarely is the integrity
of the periosteum violated by the
suppurative process. A sympathetic joint
effusion may occur and the may be
extension of the suppurative process into
the joint, although the latter is unusual.7
ROENTGEN OBSERVATIONS
The roentgen observations described here
will be limited primarily to those changes
that are seen before bone destruction or per-
Fig.1. This 12 year old Negro male presented with local pain and tenderness over the distal
metaphysis of the right femur. (A) He had no systemic symptoms. The displacement of the deep
lucent planes by the local deep soft tissue swelling in relation to the medial metaphysis is best
seen in the oblique projection (C). The left knee (B and D) is normal.
 Fig.2. (A and C) The right leg is normal. (B and D) the deep soft tissue of the left leg of this 6
year old Negro male are enlarged and there is fluid in the ankle joint. No alteration in the bones
is evident. At surgery subperiosteal pus under tension was found and cultures of the aspirates
and blood grew out Staphylococcus aureus, coagulase positive.

Iosteal new bone formation is visible.
Within the first 3 days after the onset of
symptoms, alterations in the roentgen
appearance of the soft tissue about the
metaphysis are visible. The first definite
change noted is a small, local, deep, soft
tissue swelling in the region of the
metaphysis.3 The osseous structures and
remaining soft tissues are normal
roentgenographically. The deep soft tissue
swelling is contiguous with the adjacent
bone and is apparent on the roentgenogram
by virtue of the displacement of the lucent
deep muscle plane away from bone (Fig.1,
A-D). The degree to which the lucent plane
is displaced by the deep soft tissue swelling
is frequently small and will not be
appreciated unless roentgenograms of the
opposite extremity in identical projections
are available for comparison. The roentgen
observation of the metaphyseal deep soft
tissue swelling correlates well with the time
that the vascular changes are occurring
during the early events of the inflammatory
response. When the local, deep soft tissue
swelling is visible on the roentgenogram,
there frequently will be no pus present
when the bone is drilled. The surgeon
observes, however, that the periosteum is
thickened and that bleeding is greater than
usual. Cultures of the aspirate often will
grow the offending organism. This early
stage of osteomyelitis, before the
accumulation of an exudate, is referred to as
a metaphysitis. Treatment at this stage with
surgery, appropriate antibiotics and rest
will usually abort the inflammatory process
with no subsequent significant bone
destruction resulting. Follow-up roentgeno-
 Fig.3. (A and D) There is massive enlargement
of the deep soft tissues as well as edema of the
superficial soft tissues about the right knee of
this 8 year old Negro male. Fluid within the knee
joint is evident. The bones are normal. (B and C)
The left knee is normal. At surgery there were
abcesses outside of as well as beneath the
periosteum. (E and F) one month later following
treatment there is some rarefaction at the
metaphysis and periosteal new bone formation.

grams may show a mild rarefaction in the subcutaneous soft tissue edema is the last
metaphysis and slight periosteal reaction, soft tissue change to be observed (Fig.3, A-
part of which is secondary to the surgical D). Early in this second stage the degree of
procedure. enlargement of the deep muscle may not be
sufficiently great to detect on physical
The second change in the soft tissues
examination, although the change can be
apparent roentgenographically occurs after
visualized roentgenographically (Fig.4, A-
the first few days following the onset of
F). When the bone is drilled at this time, pus
symptoms. This is manifested by swelling
is obtained, as the suppurative phase is well
of the muscles and obliteration of the lucent
established. Although considerable bone
planes between the muscles.4-6,10 The deep
destruction is present during this phase it is
muscles and lucent planes are the first to be
not visible roentgenograhically. The only
altered, followed later by involvement of
bone change that may be appreciated on the
the more superficial muscles and lucent
roentgenogram is a mild local rarefaction at
planes (Fig.1, A-D). Superficial
 Fig.4. (A) There is acute osteomyelitis of the right knee of this 7 year old Negro male. The
degree of soft tissue swelling in relation to the medial femoral metaphysis was not as obvious
clinically as that the wrist. (B) The left knee is normal.

the metaphysis which is due in part to the
hyperemia present as well as to the actual
early destruction of trabeculae. (Fig.5, A-
D). Treatment, if instituted early in this
stage, can prevent massive destruction of
bone and serious complications.
The classic roentgen picture of bone
destruction and periosteal new bone
formation is not seen until 10 or 12 days
after the onset of symptoms or after
treatment (Fig.3, E and F; and 4, G-K). The
amount of bone destruction that is visible
roentgenographically by the end of the
second week is considerably less than the
amount of actual bone destruction present.
SUMMARY
The roentgen examination can be very
helpful in makin early diagnosis of
osteomyelitis. Withis the first 2 days after
the onset of symptoms, soft tissue changes
are visible roentgenographically. A local
deep soft tissue swelling adjacent to the
metaphysis of a growing bone without
superficial edema should alert the
radiologist to the possibility of
osteomyelitis. The diagnosis is almost cert-
Fig.4. (C and E) Osteomyelitis of the right wrist. (D and F) Normal left wrist.
 Fig.4. (G and H) Three weeks following treatment there is periosteal new bone but no visible bone destruction.
Cultures of pus removal at the time of surgery grew out Staphylococcus aureus, coagulase positive.

Fig.4. (I and K) Roentgenograms of the right wrist, 3 weeks following treatment, show periosteal new bone,
but no visible bone destruction.
Fig.5. This 4 year old white female gave a history of a sore throat 1 week prior to onset of limping and 2
weeks prior to the roentgenographic examination. (A and D) Swelling of both the deep and superficial
soft tissues of the right leg is present and there is an area of bone destruction at the metaphysis of the
distal tibia. Fluid is present in the ankle joint. (B and C) The normal left leg is shown for comparison. At
surgery the periosteum was distented by a granulomatous material indicative of a chronic infection.
ain if there is also local tenderness
clinically. Several days after the onset of
symptoms. Swelling of the deep muscles
and obliteration of the lucent planes
between the muscles are visible
roentgenographically, even though the
enlargement of the deep muscles may not
be appreciated clinically. In order to
appreciate the soft tissue changes that occur
early in osteomyelitis it is most important
that the normal as well as the abnormal side
be examined roentgenographically.
Marie A. Capitanio, M.D.
Department of Radiology
St. Christophers Hospital for Children
2600 North Lawrence Street
Philadelphia, Pennsylvania 19133
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