Radiologic Case Study

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The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Vincent Y. Ng, MD, Department of Orthopaedics,The Wexner Medical Center at The Ohio "/><meta id="metaKeywords" name="keywords" content="Orthopedics,Orthopedics,Foot/Ankle,,Radiologic Case Study,"/><meta id="Meta1" name="scID"/><meta id="scID" name="scID"/><meta name="pubabbv" content="ORTHO"/><meta name="authors" content="Vincent Y. Ng MD, Erica G. Fisk MD, Thomas J. Scharschmidt MD, Joel L. Mayerson MD, Douglas Reader MD"/><meta name="articleid" content="{AA291B0F-5BD2-45A1-BD69-8EC0DC657F37}"/><meta name="legacyarticleid" content=""/><meta name="article-title" content="Radiologic Case Study"/><meta name="article-link" content="/orthopedics/journals/ORTHO/{AA291B0F-5BD2-45A1-BD69-8EC0DC657F37}/Radiologic-Case-Study"/><meta name="doi" content="10.3928/01477447-20130327-01"/><meta name="pubname" content="Orthopedics"/><meta name="pubtype" content="print"/><meta name="author" content="Vincent Y. Ng, MD"/><meta name="author" content=" Erica G. Fisk, MD"/><meta name="author" content=" Thomas J. Scharschmidt, MD"/><meta name="author" content=" Joel L. Mayerson, MD"/><meta name="author" content=" Douglas Reader, MD"/><meta name="PostedDate" content="2013-04-01"/> <meta name="specialties" content="Orthopedics"/> <meta name="specialty" content="Orthopedics"/> <meta name="primary_specialty" content="Orthopedics"/> <meta name="subspecialties" content="Foot/Ankle"/> <meta name="subspecialty" content="Foot/Ankle"/> <meta name="departments" content="Radiologic Case Study"/> <meta name="department" content="Radiologic Case Study"/> <meta name="content_type" content="Journal Article"/> <meta name="pageid" content="{AA291B0F-5BD2-45A1-BD69-8EC0DC657F37}"/> <meta property="og:image" content="https://web.archive.org/web/20130501084015im_/http://213a1ca8842e5e699a80-05ce35571e92a3f7383a191aa5840bba.r66.cf1.rackcdn.com/healio_safe_image.png"/>  <link href="https://web.archive.org/web/20130501084015cs_/http://c341130.r30.cf1.rackcdn.com/styles.css" rel="stylesheet" type="text/css"/>  <link 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<li><a href="/web/20130501084015/http://www.healio.com/orthopedics/careers" title="Careers" target=""> Careers</a> <ul class="sub_menu"> </ul> </li> </ul> <script type="text/javascript"> jQuery(".nav>li:last>a").addClass("last"); //fix for IE last-child style </script>   <div id="main-content-journals">   <p id="breadcrumbs"> <a href="/web/20130501084015/http://www.healio.com/"> Healio</a> <span>›</span> <a href="/web/20130501084015/http://www.healio.com/orthopedics"> Orthopedics</a> <span>›</span> <a href="/web/20130501084015/http://www.healio.com/orthopedics/journals"> Journals</a> <span>›</span> <a href="/web/20130501084015/http://www.healio.com/orthopedics/journals/ortho"> ORTHOPEDICS</a> </p>    <div id="SeeAlso" class="related-links"><h3>See Also</h3><ul><li><a href="https://web.archive.org/web/20130501084015/http://www.healio.com/orthopedics/journals/ortho/%7Bc71c95bb-6fd0-4a37-bb81-fc3bcc7ed6df%7D/radiologic-case-study">Radiologic Case Study</a></li><li><a href="https://web.archive.org/web/20130501084015/http://www.healio.com/orthopedics/journals/ortho/%7B202eb87d-0ea9-484c-b736-672644a6e536%7D/radiologic-case-study">Radiologic Case Study</a></li><li><a href="https://web.archive.org/web/20130501084015/http://www.healio.com/orthopedics/journals/ortho/%7B418937ac-6330-48c3-a9cc-4cd310509332%7D/radiologic-case-study">Radiologic Case Study</a></li></ul></div> <script language="javascript" type="text/javascript" xmlns:webutil="http://www.sitecore.net/webutil"></script><div class="journals-content" xmlns:webutil="http://www.sitecore.net/webutil"><div class="journal-tab-group"><ul class="journal-tabs"><li><a href="..">Current Issue</a></li><li><a href="/web/20130501084015/http://www.healio.com/orthopedics/journals/ORTHO/m/Past Issues">Past Issues</a></li></ul><div class="journal-panes"><div class="abstract-content"><p class="kicker-top">Radiologic Case Study</p><h2><a href="#">Radiologic Case Study</a></h2><p class="authors">Vincent Y. Ng, MD; Erica G. Fisk, MD; Thomas J. Scharschmidt, MD; Joel L. Mayerson, MD; Douglas Reader, MD</p><div class="journal-info"><ul class="full-text"><li class="header">Read Full Text Article</li><li class="html"><a class="active" alt="View HTML Version" rel="nofollow" title="View HTML Version" href="/web/20130501084015/http://www.healio.com/orthopedics/journals/ORTHO/{AA291B0F-5BD2-45A1-BD69-8EC0DC657F37}/Radiologic-Case-Study?full=1">HTML Icon</a></li><li class="pdf"><a target="pdfWindow" id="pdf" alt="View PDF Version" title="View PDF Version" href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/10_3928_01477447_20130327_01.pdf" rel="nofollow">PDF Icon</a></li></ul><ul class="article-citation"><li>Orthopedics</li><li>April 2013 - Volume 36 · Issue 4: 237, 308-312</li><li class="doi"> DOI: 10.3928/01477447-20130327-01</li></ul></div><div class="copyrights" style="float:right;"><a href="#" onclick="RightsLinkPopUp();"><img src="https://web.archive.org/web/20130501084015im_/http://213a1ca8842e5e699a80-05ce35571e92a3f7383a191aa5840bba.r66.cf1.rackcdn.com/request-permissions.gif" border="0" alt="Rights and Permissions"></a><script language="javascript" type="text/javascript"></script></div><h4>Abstract</h4><p>The authors are from the Department of Orthopaedics (VYN, EGF, TJS, JLM), The Wexner Medical Center at The Ohio State University; and Riverside Radiology and Interventional Associates (DR), Columbus, Ohio. </p> <p>The authors have no relevant financial relationships to disclose. </p> Correspondence should be addressed to: Vincent Y. Ng, MD, Department of Orthopaedics,The Wexner Medical Center at The Ohio State University, 376 W 10th Ave, 725 Prior Hall, Columbus, OH 43210 (vincent.ng@osumc.edu).<p> </p> <p><strong>The case: </strong> </p> <p>A 51-year-old obese man with diabetes mellitus reported a 3-week history of increasing posterior right ankle and heel pain associated with nocturnal pain, significant recent weight loss, and fevers. He denied any prior injury or trauma to this area.</p> <p> </p> <h3>Your diagnosis?</h3> <p> <a href="https://web.archive.org/web/20130501084015/http://cm.healio.com/%7E/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig6.jpg" target="_blank"><img src="https://web.archive.org/web/20130501084015im_/http://cm.healio.com/%7E/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig6.jpg" alt="Lateral radiograph (A) and sagittal T1 spin-echo (B) and T2 fat-saturated (C) magnetic resonance imaging of right foot." class="ftThumbnail"/></a></p> <p class="ftSection"> </p> <h3></h3> <p> Figure: Lateral radiograph (A) and sagittal T1 spin-echo (B) and T2 fat-saturated (C) magnetic resonance imaging of right foot.</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <h3>Diagnosis:</h3> <p><strong>Calcaneal Osteomyelitis</strong></p> <p><strong>Answer to Radiologic Case Study</strong></p> <p>A 51-year-old man presented with a 3-week history of right posterior ankle and heel pain. He reported recent weight loss, nocturnal pain, and fevers, which are red flags for either infection or malignancy of bone. Laboratory studies demonstrated an elevated white blood cell count and inflammatory markers. Physical examination revealed an inability to bear weight, significantly decreased ankle range of motion, and tenderness to palpation over the heel. Imaging studies were ordered (Figure <a href="#x01477447-20130327-01-fig1">1</a>). A subsequent bone biopsy and culture was performed, which revealed <em>methicillin-resistant Staphylococcus aureus</em> calcaneal osteomyelitis. Surgical findings of extensive retrocalcaneal purulence and invasion of the posterior tuberosity of the calcaneus during irrigation and debridement confirmed the diagnosis.</p> <p><a name="x01477447-20130327-01-fig1"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig1.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig1.jpg" alt="Lateral radiograph appears relatively normal with an area of questionable lucency in the posterior body (arrow) (A). This imaging pattern necessitated a recommendation for further advanced imaging. A T1-weighted spin-echo gradient magnetic resonance imaging (MRI) showing heterogenous marrow changes (arrows) throughout the calcaneus that are worrisome for neoplastic vs infectious etiology (B). T2-weighted fat-saturated MRI of the right foot showing involvement of the entire calcaneus with surrounding edema (arrow) in a pattern more indicative of an inflammatory/infectious etiology rather than a neoplastic one (C)." class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Figure 1: Lateral radiograph appears relatively normal with an area of questionable lucency in the posterior body (arrow) (A). This imaging pattern necessitated a recommendation for further advanced imaging. A T1-weighted spin-echo gradient magnetic resonance imaging (MRI) showing heterogenous marrow changes (arrows) throughout the calcaneus that are worrisome for neoplastic vs infectious etiology (B). T2-weighted fat-saturated MRI of the right foot showing involvement of the entire calcaneus with surrounding edema (arrow) in a pattern more indicative of an inflammatory/infectious etiology rather than a neoplastic one (C).</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> </p> <p>Osteomyelitis involves the calcaneus in 7% to 8% of cases<sup><a href="#x01477447-20130327-01-bibr1">1</a></sup> and is typically associated with recent trauma,<sup><a href="#x01477447-20130327-01-bibr2">2</a></sup> diabetes mellitus, impaired foot sensations, or puncture wounds.<sup><a href="#x01477447-20130327-01-bibr3">3</a></sup> The inability to bear weight through the heel is the most common presentation.<sup><a href="#x01477447-20130327-01-bibr1">1,2</a></sup> Local and systemic symptoms of infection such as fever, malaise, erythema, and tenderness are classic presentations.<sup><a href="#x01477447-20130327-01-bibr4">4</a></sup> The presence of a palpable bone at the base of a chronic ulcer, or the probe-to-bone test, is suggestive, although not pathognomonic, for osteomyelitis.</p> <p>Up to 60% of the bone must be demineralized before the infectious process is evident on plain radiographs.<sup><a href="#x01477447-20130327-01-bibr4">4</a></sup> Magnetic resonance imaging (MRI) findings include increased T2 signal; decreased T1 signal; concordance of T1 and T2 signal; supportive secondary signs, such as adjacent ulcers, cellulitis, abscess, and cortical destruction; and involvement in a geographic, confluent, medullary pattern rather than a hazy, reticulated, subcortical pattern.<sup><a href="#x01477447-20130327-01-bibr5">5</a></sup> In children, the mainstay of treatment is several weeks of intravenous antibiotics followed by oral antibiotics.<sup><a href="#x01477447-20130327-01-bibr2">2</a></sup> In adults, the antibiotic course is longer and surgery is more commonly required, including irrigation and debridement, partial or full amputation, and flaps for soft tissue coverage.<sup><a href="#x01477447-20130327-01-bibr3">3,4</a></sup> Antibiotic-impregnated polymethylmethacrylate or calcium sulfate beads and a staged approach with several surgeries may be successful in avoiding amputation in some cases.</p> <p> </p> <div class="ftSection"> <h3>Interpreting MRI Sequences</h3> <p>Magnetic resonance imaging has become an essential tool in every orthopedic subspecialty. Although most orthopedists are adept at interpretation of plain radiographs and even computed tomography (CT), a minority are able to decipher the many nuances of an MRI beyond the basic identification of anatomical structures. Although an exhaustive expedition into the world of physics is impractical for the average clinician, full reliance on radiologists for interpretation is equally disconcerting, especially if the musculoskeletal MRI is not being interpreted by a musculoskeletal-trained radiologist. Numerous sequences and cryptic abbreviations are associated with MRI; however, with the application of several key concepts, MRI interpretation can be simplified to a manageable level.</p> <p>Unlike CT, an MRI examination requires longer to perform because each sequence is acquired separately. Patients are scanned along the axial plane during CT and the data can be reformatted in the coronal and sagittal planes. Unless the patient is positioned obliquely in the gantry, it is difficult to obtain specific off-axis planes of imaging. MRI, on the other hand, can be obtained in different planes based on the clinical situation.</p> <p>The main types of image contrast sequencing used in musculoskeletal MRI are T1-weighted, T2-weighted, proton density, and short-tau inversion-recovery (STIR) or T2-weighted fat-suppressed imaging (Table <a href="#x01477447-20130327-01-table1">1</a>). Briefly, all tissues have a T1 relaxation time and a T2 relaxation time based on their intrinsic physical characteristics. During MRI, the parameters of time to repetition for pulse sequences and time to echo for recording of the signal after the radio-frequency pulse are adjusted. Tissues rich in protons, such as water (hydrogen protons), appear brighter on proton density, T2-weighted, and STIR images.</p> <p><a name="x01477447-20130327-01-table1"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/table1.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/table1.jpg" alt="Common Types of Musculoskeletal MRI Imagesa" class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Table 1: Common Types of Musculoskeletal MRI Images</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> </p> <p>Aside from checking the time to repetition and time to echo parameters, the most reliable way to determe the type of MRI is to look at the relative intensity of the fluid, such as cerebrospinal fluid in the spine, urine in the bladder, or synovial fluid in joint effusion. The rule most often taught is “T2: bright H<sub>2</sub>O, dark fat. T1 is the opposite.”<sup><a href="#x01477447-20130327-01-bibr6">6</a></sup> However, this can be misleading. The fat is bright with T1-weighted imaging and is hypointense with T2-weighted spin-echo sequences, but fat can be bright or hyperintense with a T2-weighted turbo spin-echo or fast spin-echo, which are more commonly used.<sup><a href="#x01477447-20130327-01-bibr7">7</a></sup> With T1-weighted imaging, fluid is typically not completely dark, but rather is of a low intermediate intensity (gray). Generally, the brightness of fluid increases gradually from T1-weighted to proton density to T2-weighted images.</p> <p>Several pulse sequence techniques are used for acquiring MRI data.<sup><a href="#x01477447-20130327-01-bibr8">8</a></sup> The technical detail that distinguishes them are beyond the scope of this article. Spin echo is the most basic sequence, but it is not as commonly used as the fast spin-echo technique, which allows for shorter scan times. Gradient-echo sequences are faster than spin-echo sequences but are more sensitive to ferromagnetic foreign body artifact. T1- and T2-weighted images can be performed with a special fat-saturation technique so that fat appears dark but the fluid intensity is unchanged. Another way to suppress the intensity of the fat signal is with inversion recovery. Short tau inversion recovery data require more time to acquire but display fat as very dark and fluid as bright. T2-weighted fat saturation and STIR images can appear similar in this regard.</p> <p>Gadolinium contrast affects T1 relaxation times and can improve the signal-to-noise ratio of the images. Given intravenously, it can help define vascular structures. By suppressing the fat signal with fat-saturation sequences, contrast-enhancing structures will stand out more.</p> <p>In general, T1-weighted images are best for defining anatomy and T2-weighted images are best for pathology. Proton-density images (Figure <a href="#x01477447-20130327-01-fig2">2</a>) are valuable for diagnosing meniscal tears, labral tears, and tendinopathy, but they are susceptible to the magic angle phenomenon. When a structure contains highly ordered collagen, such as a tendon, and is oriented approximately 55° to the main magnetic field, a falsely increased signal intensity artifact can occur within the tendon. This artifact can give the false appearance of tendinopathy because tendinopathy is typically associated with abnormally increased signal intensity within a tendon on proton density images. Short tau inversion recovery images are a useful screening tool for pathology, but STIR sequences usually have less spatial resolution than the other MRI sequences and are not as good for visualizing anatomic details. Contrast is used to screen for infection and tumors.</p> <p><a name="x01477447-20130327-01-fig2"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig2.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig2.jpg" alt="Value of proton density-weighted magnetic resonance imaging (MRI) over T1 weighting for internal derangement. Coronal T1-weighted MRI of the knee showing good anatomic detail but does not accentuate pathology well (A). This patient had an anterior cruciate ligament rupture and femoral-sided medial collateral ligament sprain. In comparison, the proton-density turbo spin-echo with fat saturation clearly delineates the healthy tendon as black and the tendon sprain as thickened and gray (B). The fluid is brighter with proton-density than T1-weighted MRI, and because the bone marrow fat has been made dark by using fat saturation, the bone bruises and effusion are better visualized on the proton-density MRI." class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Figure 2: Value of proton density-weighted magnetic resonance imaging (MRI) over T1 weighting for internal derangement. Coronal T1-weighted MRI of the knee showing good anatomic detail but does not accentuate pathology well (A). This patient had an anterior cruciate ligament rupture and femoral-sided medial collateral ligament sprain. In comparison, the proton-density turbo spin-echo with fat saturation clearly delineates the healthy tendon as black and the tendon sprain as thickened and gray (B). The fluid is brighter with proton-density than T1-weighted MRI, and because the bone marrow fat has been made dark by using fat saturation, the bone bruises and effusion are better visualized on the proton-density MRI.</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> </p> <p>Occasionally, elderly patients present with subacute pain and negative plain radiographs. Subtle fracture lines can be seen best with T1-weighted images and surrounding edema with STIR or T2-weighted fat-saturation images in which the fat from the bone marrow is purposely darkened. Another demonstrative example of the clinical application of different sequences is osteomyelitis. Normally, bone marrow appears bright on T1-weighted images due to the fat content. However, an infiltrative process such as osteomyelitis replaces the fatty marrow and decreases the T1 signal. The same area in question will appear bright or hyperintense on T2-weighted fat-saturation and STIR images due to the fluid and will typically enhance with gadolinium due to increased vascularity.</p> <p>A fluid-containing, soft tissue mass has a broad differential, but its appearance on various MRI sequences can suggest a diagnosis. A simple cyst should be homogenous and hyperintense on T2-weighted images due to its fluid content and should not enhance with gadolinium because it is not vascularized. Simple cysts such as ganglion cysts, parameniscal cysts, and paralabral cysts have thin peripheral rim enhancement. If the cystic structure has thick enhancing septations or nodular tissue enhancement within the cyst, it may be a complex cyst or, in rare cases, a soft tissue sarcoma. Abscesses usually have thicker peripheral rim enhancement with gadolinium and have surrounding edema on T2-weighted images (Figure <a href="#x01477447-20130327-01-fig3">3</a>). Soft tissue sarcomas are typically enhanced within the substance of the mass because they are vascularized, with the exception of necrotic, cystic, and hemorrhagic areas (Figure <a href="#x01477447-20130327-01-fig4">4</a>).</p> <p><a name="x01477447-20130327-01-fig3"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig3.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig3.jpg" alt="Role of T2-weighted fat saturation and intravenous gadolinium in osteomyelitis. Coronal short-tau inversion-recovery magnetic resonance imaging (MRI) of the hip showing a homogenous, fluid-filled collection with edema in the greater trochanter (A). The fluid is dark on the T1-weighted turbo spin-echo MRI, and the involved greater trochanter appears dark, suggesting replacement of the bright fatty marrow with osteomyelitis (B). On the axial T2-weighted turbo spin-echo MRI, not only does the fluid appear bright, but the fat does as well. Note that the surrounding tissues are inflamed, suggesting an infectious process rather than a simple cyst (C). A T1-weighted, turbo spin-echo, fat-saturation MRI with intravenous contrast showing peripheral enhancement (rim-enhancing) (D). This suggests that the lesion itself is not vascularized and that the intravenous contrast does not perfuse through it. This patient had a soft tissue abscess with adjacent osteomyelitis of the greater trochanter." class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Figure 3: Role of T2-weighted fat saturation and intravenous gadolinium in osteomyelitis. Coronal short-tau inversion-recovery magnetic resonance imaging (MRI) of the hip showing a homogenous, fluid-filled collection with edema in the greater trochanter (A). The fluid is dark on the T1-weighted turbo spin-echo MRI, and the involved greater trochanter appears dark, suggesting replacement of the bright fatty marrow with osteomyelitis (B). On the axial T2-weighted turbo spin-echo MRI, not only does the fluid appear bright, but the fat does as well. Note that the surrounding tissues are inflamed, suggesting an infectious process rather than a simple cyst (C). A T1-weighted, turbo spin-echo, fat-saturation MRI with intravenous contrast showing peripheral enhancement (rim-enhancing) (D). This suggests that the lesion itself is not vascularized and that the intravenous contrast does not perfuse through it. This patient had a soft tissue abscess with adjacent osteomyelitis of the greater trochanter.</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> <a name="x01477447-20130327-01-fig4"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig4.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig4.jpg" alt="Appearance of soft-tissue sarcoma on magnetic resonance imaging (MRI). Coronal short-tau inversion-recovery (STIR) MRI of the thigh showing a heterogenous soft tissue mass (A). Note that everything appears dark except the mass, which has heterogeneously high fluid content. The axial T2-weighted fat-saturation MRI has a similar bright-dark pattern as the STIR sequence, in which everything is dark except for the mass and the fluid in the vessels (B). On the T1-weighted MRI, the fat is bright, but the mass is dark and hard to appreciate because it blends in with the adjacent musculature (C). The T1-weighted fat-saturation MRI (D) showing that both the fluid and fat have low intensity is acquired for comparison with the T1-weighted fat saturation with contrast images (E). Unlike an abscess or a cyst in which the lesion is rim-enhancing, this soft tissue sarcoma is well-perfused and demonstrates extensive uptake of the contrast. Note also how the sarcoma expands the surrounding musculature rather than tracking along fascial or intermusculular planes." class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Figure 4: Appearance of soft-tissue sarcoma on magnetic resonance imaging (MRI). Coronal short-tau inversion-recovery (STIR) MRI of the thigh showing a heterogenous soft tissue mass (A). Note that everything appears dark except the mass, which has heterogeneously high fluid content. The axial T2-weighted fat-saturation MRI has a similar bright-dark pattern as the STIR sequence, in which everything is dark except for the mass and the fluid in the vessels (B). On the T1-weighted MRI, the fat is bright, but the mass is dark and hard to appreciate because it blends in with the adjacent musculature (C). The T1-weighted fat-saturation MRI (D) showing that both the fluid and fat have low intensity is acquired for comparison with the T1-weighted fat saturation with contrast images (E). Unlike an abscess or a cyst in which the lesion is rim-enhancing, this soft tissue sarcoma is well-perfused and demonstrates extensive uptake of the contrast. Note also how the sarcoma expands the surrounding musculature rather than tracking along fascial or intermusculular planes.</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> </p> <p>Orthopedists should beware of hematomas, particularly if they are not precipitated by a significant trauma and are not associated with superficial ecchymosis because they could be the result of hemorrhage within a tumor capsule. Hematomas often have a swirled, heterogeneous appearance on MRI and change intensities over time (Figure <a href="#x01477447-20130327-01-fig5">5</a>). Within the first 6 hours of bleeding (hyperacute), a hematoma will appear similar to fluid and be bright on T2-weighted images and dark on T1-weighted images. It may enhance with gadolinium if there is active bleeding or if there is a solid tumor element within it. In the acute phase (1 to 3 days after injury), the hematoma will become hypointense on both T1- and T2-weighted images with the deposition of clotting factors. Subacutely (4 to 7 days after injury), the intracellular methemoglobin will cause appear hyperintense on T1-weighted images and will remain dark or gray on T2-weighted images. In late subacute hematomas (more than 1 week after injury), hemolysis will occur and extracellular methemoglobin will cause increased intensity on both T1- and T2-weighted images. All hematomas should be followed clinically to con-firm resolution; 1 month after injury, chronic hematomas will have a dark halo around the periphery from hemosiderin and have a hyperintense central portion from methemoglobin on both T1- and T2-weighted images.<sup><a href="#x01477447-20130327-01-bibr9">9</a></sup></p> <p><a name="x01477447-20130327-01-fig5"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig5.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/fig5.jpg" alt="Features of hematoma on magnetic resonance imaging (MRI). A coronal T1-weighted turbo spin-echo MRI of a hematoma showing a heterogenous mass with areas of high signal intensity, indicating the presence of methemoglobin typically found in late subacute hematomas (A). A coronal STIR MRI showing a dark rim of hemosiderin or fibrosis around a chronic portion of the hematoma (B). On the axial T1-weighted, turbo spin-echo, fat-saturation MRI with contrast, note how it is mildly rim-enhancing and how it tracks along tissue planes between the deep and superficial posterior compartments of the leg (C)." class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Figure 5: Features of hematoma on magnetic resonance imaging (MRI). A coronal T1-weighted turbo spin-echo MRI of a hematoma showing a heterogenous mass with areas of high signal intensity, indicating the presence of methemoglobin typically found in late subacute hematomas (A). A coronal STIR MRI showing a dark rim of hemosiderin or fibrosis around a chronic portion of the hematoma (B). On the axial T1-weighted, turbo spin-echo, fat-saturation MRI with contrast, note how it is mildly rim-enhancing and how it tracks along tissue planes between the deep and superficial posterior compartments of the leg (C).</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> </p> <p>In the current study, plain radiographs did not provide adequate information to elucidate an acceptable differential diagnosis. Advanced imaging was necessary to raise the question of osteomyelitis vs neoplasm. Magnetic resonance imaging sequences demonstrated marrow changes were most consistent with an infectious etiology and led to appropriate workup, including biopsy and cultures. Treatment included surgical debridement and intravenous antibiotics. Understanding the differences between the various sequences is crucial to proper interpretation of MRI scans. Although the physics behind this powerful technology is beyond the grasp and time of the average orthopedist, a working knowledge of the relative intensity of contrast based on MRI sequence parameters is valuable in several clinical situations (Table <a href="#x01477447-20130327-01-table2">2</a>).</p> <p><a name="x01477447-20130327-01-table2"></a> <table class="ftFigure"> <tbody> <tr> <td class="ftGraphicThumbnail"><a href="/web/20130501084015/http://www.healio.com/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/table2.jpg" target="_blank"><img src="/web/20130501084015im_/http://www.healio.com/orthopedics/journals/ORTHO/%7BAA291B0F-5BD2-45A1-BD69-8EC0DC657F37%7D/~/media/Journals/ORTHO/2013/4_April/10_3928_01477447_20130327_01/table2.jpg" alt="Quick Tips for Busy Orthopedists" class="ftThumbnail"/></a></td> <td class="ftFigureCaption"></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p class="ftFloatLeft">Table 2: Quick Tips for Busy Orthopedists</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p></td> </tr> </tbody> </table> </p> </div> <div class="ftRefList"> <h3>References</h3> <ol><a name="x01477447-20130327-01-bibr1"></a> <li> Wang EHM, Simpson S, Bennet GC. Osteomyelitis of the calcaneum. <em>J Bone Joint Surg Br</em>. 1992; 74:906–909.</li> <a name="x01477447-20130327-01-bibr2"></a> <li> Leigh W, Crawford H, Street M, Huang M, Manners S, Puna R. Pediatric calcaneal osteomyelitis. <em>J Pediatr Orthop</em>. 2010; 30:888–892 doi:10.1097/BPO.0b013e3181fa7955<a href="https://web.archive.org/web/20130501084015/http://dx.doi.org/10.1097/BPO.0b013e3181fa7955" target="_blank"> [CrossRef]</a> .</li> <a name="x01477447-20130327-01-bibr3"></a> <li> Laughlin RT, Mader JT, Calhoun JH, Foad A. Calcaneal osteomyelitis: an analysis of aetiology and pathogenic organisms. <em>Foot Ankle Surg</em>. 1999; 5:171–177 doi:10.1046/j.1460-9584.1999.00158.x<a href="https://web.archive.org/web/20130501084015/http://dx.doi.org/10.1046/j.1460-9584.1999.00158.x" target="_blank"> [CrossRef]</a> .</li> <a name="x01477447-20130327-01-bibr4"></a> <li> Chen K, Balloch R. Management of calcaneal osteomyelitis. <em>Clin Podiatr Med Surg</em>. 2010; 27:417–429 doi:10.1016/j.cpm.2010.04.003<a href="https://web.archive.org/web/20130501084015/http://dx.doi.org/10.1016/j.cpm.2010.04.003" target="_blank"> [CrossRef]</a> .</li> <a name="x01477447-20130327-01-bibr5"></a> <li> Collins MS, Schaar MM, Wenger DE, Mandrekar JN. T1-weighted MRI characteristics of pedal osteomyelitis. <em>AJR Am J Roentgenol</em>. 2005; 185:386–393 doi:10.2214/ajr.185.2.01850386<a href="https://web.archive.org/web/20130501084015/http://dx.doi.org/10.2214/ajr.185.2.01850386" target="_blank"> [CrossRef]</a> .</li> <a name="x01477447-20130327-01-bibr6"></a> <li> Understanding MRI from an orthopedic perspective. <em>Orthopedics Today</em>. October2004. <a href="https://web.archive.org/web/20130501084015/http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedicstoday/%7B1ac19708-205b-41f5-bd99-4478eb068dba%7D/understanding-mri-from-an-orthopedic-perspective" target="_blank">http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedicstoday/%7B1ac19708-205b-41f5-bd99-4478eb068dba%7D/understanding-mri-from-an-orthopedic-perspective</a>. Accessed March 21, 2013.</li> <a name="x01477447-20130327-01-bibr7"></a> <li> Pretorius ES, Solomon JA. <em>Radiology Secrets</em>. Philadelphia, PA: Elsevier Mosby; 2006.</li> <a name="x01477447-20130327-01-bibr8"></a> <li> Bitar R, Leung G, Perng R, et al. MR pulse sequences: what every radiologist wants to know but is afraid to ask. <em>Radiographics</em>. 2006; 26:513–537 doi:10.1148/rg.262055063<a href="https://web.archive.org/web/20130501084015/http://dx.doi.org/10.1148/rg.262055063" target="_blank"> [CrossRef]</a> .</li> <a name="x01477447-20130327-01-bibr9"></a> <li> Breitenseher M. <em>MR Imaging Strategies for the Lower Extremities</em>. 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Radiologic Case Study | Orthopedics