Osteomyelitis is an increasingly common pathology that often poses a diagnostic challenge to clinicians. Accurate and timely diagnosis is critical to preventing complications that can result in the loss of life or limb. In addition to history, physical exam, and laboratory studies, diagnostic imaging plays an essential role in the diagnostic process. This narrative review article discusses various imaging modalities employed to diagnose osteomyelitis: plain films, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, bone scintigraphy, and positron emission tomography (PET). Articles were obtained from Pubmed and screened for relevance to the topic of diagnostic imaging for osteomyelitis. The authors conclude that plain films are an appropriate first step, as they may reveal osteolytic changes and can help rule out alternative pathology. MRI is often the most appropriate second study, as it is highly sensitive and can detect bone marrow changes within days of an infection. Other studies such as CT, ultrasound, and bone scintigraphy may be useful in patients who cannot undergo MRI. CT is useful for identifying necrotic bone in chronic infections. Ultrasound may be useful in children or those with sickle-cell disease. Bone scintigraphy is particularly useful for vertebral osteomyelitis. Finally, PET scan has demonstrated high sensitivity and specificity; however, its clinical application is limited by its high cost and poor availability. When used appropriately, diagnostic imaging can provide high sensitivity and specificity for detecting osteomyelitis, making radiographic evaluation a crucial step in the diagnostic process of this debilitating condition.

Conflict(s) of Interest

Dr. Shuler serves on the editorial committee of the Marshall Journal of Medicine. The other authors have no conflicts of interest to disclose.

References with DOI

1. Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ, 3rd, Huddleston PM, 3rd. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015;97(10):837-45. http://dx.doi.org/10.2106/jbjs.n.01350

2. Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. Phys Sportsmed. 2008;36(1):nihpa116823-nihpa. http://dx.doi.org/10.3810/psm.2008.12.11

3. Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Seminars in arthritis and rheumatism. 2009;39(1):10-7. http://dx.doi.org/10.1016/j.semarthrit.2008.03.002

4. Concia E, Prandini N, Massari L, Ghisellini F, Consoli V, Menichetti F, et al. Osteomyelitis: clinical update for practical guidelines. Nuclear medicine communications. 2006;27(8):645-60. http://dx.doi.org/10.1097/00006231-200608000-00007

5. Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Seminars in Plastic Surgery. 2009;23(2):80-9. http://dx.doi.org/10.1055/s-0029-1214160

6. Kothari NA, Pelchovitz DJ, Meyer JS. Imaging of musculoskeletal infections. Radiologic clinics of North America. 2001;39(4):653-71. http://dx.doi.org/10.1016/s0033-8389(05)70304-3

7. Lew DP, Waldvogel FA. Osteomyelitis. Lancet (London, England). 2004;364(9431):369-79. http://dx.doi.org/10.1016/s0140-6736(04)16727-5

8. Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. American family physician. 2011;84(9):1027-33.

9. Jevtic V. Vertebral infection. European radiology. 2004;14 Suppl 3:E43-52. http://dx.doi.org/10.1007/s00330-003-2046-x

10. Towers JD. The use of intravenous contrast in MRI of extremity infection. Semin Ultrasound CT MR. 1997;18(4):269-75. http://dx.doi.org/10.1016/s0887-2171(97)80017-0

11. Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. Archives of internal medicine. 2007;167(2):125-32. http://dx.doi.org/10.1001/archinte.167.2.125

12. Wertman R, Altun E, Martin DR, Mitchell DG, Leyendecker JR, O'Malley RB, et al. Risk of nephrogenic systemic fibrosis: evaluation of gadolinium chelate contrast agents at four American universities. Radiology. 2008;248(3):799-806. http://dx.doi.org/10.1148/radiol.2483072093

13. Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(11):2464-71. http://dx.doi.org/10.2106/00004623-200511000-00013

14. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2015;61(6):e26-46. http://dx.doi.org/10.1093/cid/civ482

15. Santiago Restrepo C, Gimenez CR, McCarthy K. Imaging of osteomyelitis and musculoskeletal soft tissue infections: current concepts. Rheum. Dis. Clin. North Am. 2003;29(1):89-109. http://dx.doi.org/10.1016/s0889-857x(02)00078-9

16. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR American journal of roentgenology. 1992;158(1):9-18. http://dx.doi.org/10.2214/ajr.158.1.1727365

17. Littenberg B, Mushlin AI. Technetium bone scanning in the diagnosis of osteomyelitis: a meta-analysis of test performance. Diagnostic Technology Assessment Consortium. Journal of general internal medicine. 1992;7(2):158-64. http://dx.doi.org/10.1007/bf02598005

18. Bohndorf K. Infection of the appendicular skeleton. European radiology. 2004;14 Suppl 3:E53-63. http://dx.doi.org/10.1007/s00330-003-2039-9

19. Cierny G, 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin. Orthop. Relat. Res. 2003(414):7-24.

20. Stumpe KD, Strobel K. 18F FDG-PET imaging in musculoskeletal infection. The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the So. 2006;50(2):131-42.

21. Cardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in musculoskeletal infections. Radiologic clinics of North America. 2001;39(2):191-201. http://dx.doi.org/10.1016/s0033-8389(05)70272-4

22. 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. Clinical radiology. 1999;54(10):636- 9. http://dx.doi.org/10.1016/s0009-9260(99)91081-4

23. Larcos G, Antico VF, Cormick W, Gruenewald SM, Farlow DC. How useful is ultrasonography in suspected acute osteomyelitis? Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 1994;13(9):707-9.

24. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. The Journal of Bone & Joint Surgery. 2003;85(1):1-3. http://dx.doi.org/10.2106/00004623-200301000-00001

25. Buzzle. Bone Scan Cost [cited 2016 4/25]. Available from: http://www.buzzle.com/articles/bone-scancost.html.

26. Oakwood. Radiology Actual Pricing [cited 2016 4/25]. Available from: https://www.oakwood.org/?id=1561&sid=9&ChargeType=Radiology.