MSK Infection

Infection

By: Dr. Abdullah Nouh

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MSK Infection
Succeeding
Get through
Barret1
Barret2
(Ped) 63 A 6 year old boy presents with worsening left knee pain, but no history of trauma. X-ray reveals a 1.5
cm lytic, oval lesion in the proximal tibial metaphysis. There is a surrounding rim of sclerosis with a lucent
channel extending towards the growth plate. What is the most likely diagnosis?
(a) Brodie abscess
(b) Chondroblastoma
(c) Ewing's sarcoma
(d) Osteoid osteoma
(e) Multiple myeloma

63 (a)
Brodie abscess is a subacute pyogenic osteomyelitis, most commonly caused by Staphylococcus aureus. It is a
metaphyseal lesion, but may cross to the epiphysis before growth plate fusion; the proximal or distal tibia location
is typical. The finding of a lucent channel extending to the physis ('serpentine' sign) is pathognomonic for Brodie
abscess.
70 A 35 year old intravenous drug abuser presents complaining of pain in his great toe. On questioning, he has
been using foot veins to inject drugs. Which of the following statements is incorrect regarding his risk of
osteomyelitis?
(a) Staphylococcus aureus is the likeliest organism
(b) Initial plain radiographs may be normal
(c) Localized soft tissue swelling occurs within 2 weeks
(d) A sequestrum is not seen until at least a month after the insult
(e) Radiographs are not sensitive detectors of osteomyelitis

70 (a)
Pseudomonas is the commonest responsible organism in drug users. S. aureus is the commonest responsible
organism in non-diabetics. Diabetic patients typically have multiple responsible organisms. Plain films can be
normal for up to 2 weeks. The earliest sign is soft tissue swelling. Other signs include osteolysis, endosteal
erosion, and the formation of an involucrum, followed by a sequestrum.
Currie
Grainger
Gupta
48. A 60-year-old diabetic man with a 7-day-old compound fracture of the right tibia and fibula develops fever
and septicaemia. Radiography of the leg shows a fracture of the mid shaft of tibia and fibula, along with extensive
air in soft tissues extending to ankle and knee. What is the most likely diagnosis?
(a) Air secondary to compound fracture
(b) Aerobic bacterial infection
(c) Clostridium infection
(d) Staphylococcus infection
(e) Beta-haemolytic streptococci

48. (c) Clostridium infection

Gas in the soft tissues after compound fractures is a manifestation of infection. Gas gangrene after Clostridium
infection is a classical example and causes extensive oedema, necrosis of tissues with gas production resulting in
a severe toxic state. Other gas-forming organisms include anaerobic bacteria, coliforms and Bacteroides.

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Oxford
34. A patient who is HIV positive presents with knee and ankle pain and swelling. Clinical examination is
otherwise unremarkable. Initial radiographs reveal only a joint effusion. The complaint resolves after 4
weeks. What is the most likely diagnosis?
A. Septic arthritis.
B. Psoriatric arthritis.
C. HIV-associated arthritis.
D. Acute symmetric polyarthritis.
E. Hypertrophic pulmonary osteoarthropathy (HPOA).

34. C. HIV-associated arthritis.

This is oligoarticular, asymmetric and peripheral. It primarily affects the knees and ankles. It has a short duration
of 1–6 weeks; radiography may reveal a joint effusion. Acute symmetric polyarthritis also occurs in HIV. It
behaves clinically like RA, but patients are negative for rheumatoid factor. Features that help differentiate it from
RA are periostitis and proliferative new bone formation. Occasionally an erosive variety with little or no
proliferative bone formation occurs. Psoriatric arthritis has a higher prevalence among AIDS patients than in the
general population. HPOA is associated with P carinii pneumonia (PCP) in AIDS. Plain fi lms reveal periosteal
reaction. Kaposi’s sarcoma uncommonly affects the bone, but does so most commonly in Africa. Non- Hodgkin
lymphoma (NHL) is the second most common tumour in HIV infection. It can produce lytic, sclerotic, or mixed
lesions with a wide zone of transition; they are usually lytic. Other musculoskeletal complications in AIDS include
infections (cellulitis, osteomyelitis, septic arthritis, pyomyositis, necrotising fasciitis), Reiter’s syndrome,
undifferentiated spondyloarthropathy, polymyositis, osteonecrosis (especially of the femoral head), osteoporosis,
rhabdomyolysis, and anaemia.
42. An 81-year-old male diabetic is referred from the endocrinology team for an MRI of foot. This patient
was seeing a podiatrist, who became concerned that the foot had become increasingly deformed and was
acutely red and swollen around the tarso-metatarsal joints. The patient is asymptomatic as he has
peripheral neuropathy. The clinical query is whether this patient has osteomyelitis/septic arthritis in this
region, or neuropathic arthropathy. Which of these MRI features would be more typically associated with
osteomyelitis than acute neuropathic arthropathy?
A. Focal involvement.
B. Predominant midfoot involvement.
C. Associated bony debris.
D. High T2WI and STIR, low T1WI. Enhancement present.
E. Bony changes are in a periarticular and subchondral location.

42. A. Focal involvement.

Whilst differentiating these conditions can be difficult and they frequently overlap, there are certain features that
can be of value. Neuropathic arthropathy (NA) seldom affects a single bone/ joint in the foot, and is most common
in the midfoot region. As such a more focal abnormality, or abnormality affecting the metatarsal heads, or other
points of pressure, should indicate osteomyelitis. Whilst high T2WI/STIR, low T1WI and enhancement are seen
in osteomyelitis, it is also seen in acute NA and as such is not a good differentiating factor. The converse is not
true, where low signal on T1WI and T2WI, typical of chronic NA, would make the presence of osteomyelitis
unlikely.
MasterPass1
50 A 27-year-old Afro-Caribbean patient with known sickle cell disease presented with ongoing pain left arm
pain following a crisis and was found to have osteomyelitis of his humerus. What is the most likely causative
organism?
a Proteus mirabilis
b Escherichia coli
C Staphylococcus aureus
d Mycoplasrna pneumoniae
e Corynebacteriurn diphtheriae

50 Answer C: Staphylococcus aureus

Some series suggest that Salmonella is the most likely cause but others have found that Staphylococcus is the
commonest cause in this population.

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MasterPass2
9 A 10-year-old schoolboy had a fall and bruised his right knee badly. There was an open wound that was not
treated until the following day. After a further two days he became systemically unwell with a fever. His knee
was extremely tender, swollen, and the movement was restricted. Which of the following is a feature of septic
arthritis?
a Usually due to Haernophilus
b Periarticular, soft tissue swelling is rare
C Blurring of the periarticular fat planes is common
d The joint space widens after a few weeks
e A joint effusion is not usually present

9 Answer C: Blurring of the periarticular fat planes is common

Septic arthritis usually occurs in hip, knee, shoulder, elbow and ankle. Staphylococcus aureus, followed by group
A Streptococcus, are the most common causes. Other radiographic features include periarticular soft-tissue
swelling, an effusion, periarticular osteopenia and, later, joint space narrowing. Ultrasound may help identify
septic arthritis before cartilage lysis occurs. hallmark is joint eff. in a patient with signs of a joint infection.
66 A 12-year-old boy presented with ankle pain and a radiograph showed a metaphyseal lucency with dense
surrounding sclerosis with a thin lucent channel extending towards the growth plate. The lesion was thought to
be a Brodie's abscess. What is the most likely causative organism?
a Proteus mirabilis
b Escherichia coli
c Staphylococcus aureus
d Salmonella species
e Streptococcus milleri
66 Answer C: Staphylococcus aureus
Brodie's abscesses are more common in children and tend to affect the end of tubular bones, most commonly the
distal tibia or femur.
MasterPass3
(Ped) 24 A five-year-old girl is systemically unwell with left leg pain and a limp. On examination she is
exquisitely tender over the left femur. Staphylococcus aureus is grown from her blood cultures. A plain radiograph
of the left leg confirms the diagnosis of osteomyelitis. Where is the abnormality likely to be?
a Femoral metaphysis
b Femoral epiphysis
C Femoral diaphysis
d Distal femoral physis
e Multicentric involvement

24 Answer A: Femoral metaphysis

Osteomyelitis is often the result of haematogenous spread in the paediatric population. In neonates there is
commonly multicentric involvement. In children from 18 months to 18 years the metaphyseal vessels loop sharply
without penetrating the growth plate, therefore the metaphysis is most commonly affected.
Grainger
QUESTION 28
An elderly diabetic patient with an established peripheral senso1y neuropathy has deep ulcers on his right foot.
Plain films show destruction of the architecture of the midfoot with extensive sclerosis, consistent with a Charcot
arthropathy. Which imaging feature would suggest coexistent infection?
A Collapse of the plantar arch on the lateral radiograph
B Enhancement of Tl w signal following administration of gadolinium
C Evidence of bone oedema on fluid sensitive sequences
D Reduced bone marrow signal on STIR
E Slow progression of bone destruction on serial radiographs

ANSWER: B
The detection, or exclusion, of osteomyelitis in the context of Charcot arrhropathy is difficult. Bone marrow
oedema is a feature of both infection and Charcot changes, but enhancement following gadolinium is suspicious
for coexistent infection.

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QUESTION 35
A 19-year-old student returns to the UK following 4 months' travelling around the world. Radiographs reveal
multiple oval areas of calcification, up to 1 cm in long axis, aligned in the direction of muscle fibres. What is the
most likely diagnosis?
A Cysticercosis
B Dracunculus (guinea worm) infection
C Hydatid disease
D Loiasis
E Schistosomiasis

ANSWER: A
A 75-year-old diabetic man underwent a left below knee amputation 3 months ago for osteomyelitis of the distal
tibia. Since then, he has experienced recurrent episodes of fever and malaise. MRI is contraindicated due to a
metallic aortic valve. Which is the best investigation to exclude an occult focus of osteomyelitis?
A CT
B US
C Scintigraphy using gallium
D Scintigraphy using indium-labelled white cells
E Scintigraphy using technetium (Tc-99m) monodiphosphonate

ANSWER:E
Although an indium-labelled white cell study is more specific, a bone scintigram using Tc-99m
monodiphosphonate is a more sensitive test to exclude osteomyelitis.

QUESTION 59
An 80-year-old diabetic man is admitted from the Emergency Department with clinical and radiographic features
consistent with a septic arthritis of the right hip. There is no history of trauma or previous surgery. Initial blood
cultures indicate a systemic bacteraemia. What is the most likely organism to be cultured?
A Clostridium difficile
B Haemophilus influenzae
C Pseudomonas aeruginosa
D Staphylococcus aureus
E Streptococcus pneumoniae

ANSWER: D
Streptococcus pneumoniae and Haemophilus influenzae are potential causes of primary bacteraemia and
haematogenous infection of joints, but substantially less common than Staphylococcus aureus.
EDiR Questions
35. Regarding imaging appearances of osteomyelitis:
(a) Klebsiella is the commonest organism isolated in adult
(b) Chronic osteomyelitis is characterised by prominent cortical thinning
(c) The diaphysis are often spared in patients with sickle cell disease.
(d) Radiographic findings become evident approximately 3 days after onset infection
(e) Periosteal reaction is the earliest sign of acute osteomyelitis

Answers:
(a) Not correct
(b) Not correct
(c) Not correct
(d) Not correct
(e) Not correct
Explanation:
Radiographic findings of osteomyelitis become evident approximately at 1-2 weeks after onset of infection.
Soft tissue swelling and loss of normal fat planes is the earliest sign of acute osteomyelitis.
The staphylococcus is the commonest organism involved.
Chronic osteomyelitis is characterised by prominent cortical thickening.
In sickle cell disease, diaphysis is the primary focus of infection.