Benefits of diffusion-weighted imaging in pediatric acute osteoarticular infections

[Arthritis and osteomyelitis in childhood and adolescence-Bacterial and nonbacterial]

Bacterial arthritis and osteomyelitis are usually acute diseases, which in this way differ from the often insidious course of nonbacterial osteomyelitis; however, there is often an overlap both in less acute courses of bacterial illnesses and also in nonbacterial osteitis. The overlapping clinical phenomena can be explained by similar pathophysiological processes. In bacteria-related illnesses the identification of the pathogen and empirical or targeted anti-infectious treatment are prioritized, whereas no triggering agent is known for nonbacterial diseases. The diagnostics are based on the exclusion of differential diagnoses, clinical scores and magnetic resonance imaging (MRI). An activity-adapted anti-inflammatory treatment is indicated.

Rapid MRI for acute pediatric MSK infections: survey of current utilization and procedural practices

BACKGROUND

Some institutions have implemented rapid MRI protocols for acute musculoskeletal (MSK) infections as an attempt to improve early diagnosis.

OBJECTIVE

To assess current utilization of pediatric rapid MSK MRI protocols (abbreviated protocol, no IV (intravenous) contrast, and no sedation) using a survey.

MATERIALS AND METHODS

A 10-question survey was sent to members of the Society for Pediatric Radiology (SPR) and the Society of Skeletal Radiology, which differed depending on whether a rapid protocol was used or not. The survey was conducted by the SPR MSK and MRI committees.

RESULTS

A total of 134 surveys (representing 99 institutions) were completed. Twenty-two percent (22/99) of institutions used a rapid protocol. Pediatric institutions were more likely to perform it when compared to adult institutions (P-value<0.01, 37% (14/38) vs. 13% (8/61)). Comparing institutions that use rapid protocol with institutions that do not, the availability of on-call MRI technologists did not differ (P-value=0.33), and pediatric radiologists were more likely to interpret these studies (73% (16/22) vs. 36% (28/77), P-value=0.02). Reported rapid MRI completion times took less than 15 min in 64% (14/22) of the institutions. Seventy-three percent (16/22) of institutions performing rapid protocols have radiologists check images to evaluate the need for additional sequences or contrast. Sixty-eight percent (25/37) reported being very satisfied with rapid protocols. Seventy-seven of 99 institutions do not use a rapid protocol due to a lack of a consensus protocol and concerns about missing findings. Of these institutions, 62% (48/77) administer IV contrast routinely.

CONCLUSION

There is limited and variable utilization of rapid MRI protocols for acute pediatric MSK infection. Lack of accepted consensus protocol is the most common reason for non-implementation, highlighting the need for consensus-driven rapid protocols.

The beauty of pediatric musculoskeletal ultrasound

Ultrasound is a powerful technique in pediatric imaging and musculoskeletal (MSK) imaging in many specific clinical scenarios. This article will feature some common and less common spot diagnoses in pediatric musculoskeletal ultrasound.Cases were collected by members of the Educational Committee of the ESSR (European Society of musculoSkeletal Radiology) and the Pediatric Subcommittee of the ESSR with expertise in musculoskeletal ultrasound.Fifteen clinical entities are discussed based on the features that allow diagnosis by ultrasound.Clinical history, location, and ultrasound appearance are the keys to spot diagnoses when performing pediatric musculoskeletal ultrasound. · Ultrasound in pediatric musculoskeletal imaging can achieve a diagnosis in specific clinical settings.. · Clinical history, location, and ultrasound appearance are keys to spot diagnoses.. · Knowledge of spot diagnoses in pediatric musculoskeletal ultrasound facilitates daily clinical practice.. · Drakonaki EE, Adriaensen M, Simoni P et al. The beauty of pediatric musculoskeletal ultrasound. Rofo 2025; 197: 172-185.

Diagnosis and management of septic arthritis: A current concepts review

Correct diagnosis and treatment of septic arthritis (SA) are essential to achieve satisfactory results and avoid lifelong consequences. Diagnosing septic arthritis is not always easy, which is why new biomarkers have been sought. Another difficulty in diagnosis is the increase in septic arthritis due to Kingella Kingae, which does not show the same signs and symptoms as classic Staphylococcus aureus infections. Increasingly, magnetic resonance imaging plays a more fundamental role in diagnosing septic arthritis, and many studies are focused on this line, especially for the study of associated pathologies. Numerous studies have been published on less invasive treatments for septic arthritis, although the evidence suggests that the results should be taken cautiously. Although most of the published studies focus on the hip and knee, there have also been recent publications on SA in the upper limb, foot, and ankle. Finally, the literature also pays attention to SA in young children due to its different etiology and the greater difficulties in its diagnosis.

Bacterial osteomyelitis in pediatric patients: a comprehensive review

Bacterial osteomyelitis, an inflammatory response in the bone caused by microorganisms, typically affects the metaphysis in the skeletally immature. Bacterial osteomyelitis possesses a significant diagnostic challenge in pediatric patients due to its nonspecific clinical presentation. Because the metaphysis is the primary focus of infection in skeletally immature patients, understanding the normal physiologic, maturation process of bones throughout childhood allows to understand the pathophysiology of osteomyelitis. Timely and accurate diagnosis is crucial to initiate appropriate treatment, and prevent long-term sequelae and efforts must be made to isolate the causative organism. The potential causative organism changes according to the age of the patient and underlying medical conditions. Staphylococcus Aureus is the most common isolated bacteria in pediatric pyogenic osteomyelitis whereas Kingella Kingae is the most common causative agent in children aged 6 months to 4 years. Imaging plays a pivotal role in the diagnosis, characterization, evaluation of complications, and follow up of bacterial osteomyelitis. Imaging also plays a pivotal role in the evaluation of potential neoplastic and non-neoplastic mimickers of osteomyelitis. In children, MRI is currently the gold standard imaging modality when suspecting bacterial osteomyelitis, whereas surgical intervention may be required in order to isolate the microorganism, treat complications, and exclude mimickers.

State of the art in the diagnostic evaluation of osteomyelitis: exploring the role of advanced MRI sequences-a narrative review

Background and Objective

Osteomyelitis, a severe bone infection caused mainly by pyogenic organisms, poses diagnostic challenges due to its non-specific magnetic resonance imaging (MRI) manifestations. Conventional MRI, though the imaging modality of choice, often exhibits signal abnormalities with overlapping differential diagnoses, potentially leading to overestimation of infection extent and duration. To address these limitations, advanced MRI sequences, including dynamic contrast-enhanced (DCE) MRI, 1H magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), and Dixon techniques have emerged as promising alternatives. This narrative review explores the potential role of these sequences in aiding the differential diagnosis of osteomyelitis.

Methods

We used the PubMed database to search for relevant articles using the MeSH keywords: (osteomyelitis) AND (advanced MRI sequences) and we manually selected the most suitable studies to include in our review. Articles outside of original studies were also included. Only records in English or French were considered.

Key Content and Findings

In particular, DWI is useful for characterizing fluid collections, distinguishing bone infarcts, and bacterial skull base osteomyelitis from neoplastic lesions. Moreover, DWI assists in differentiating diabetic foot osteomyelitis (DFO) from Charcot neuro-osteoarthropathy, facilitates the diagnosis of pediatric acute osteoarticular infections, and aids in distinguishing osteomyelitis from Modic I degenerative changes. Additionally, DWI proves valuable in monitoring spinal infections and distinguishing pedal osteomyelitis from other conditions, even in patients with renal impairment. DCE-MRI enhances MRI specificity by assessing contrast uptake over time, providing valuable insights into inflammatory microenvironments. It aids in detecting DFO, differentiating it from acute Charcot arthropathy, and distinguishing osteomyelitis from neuropathic arthropathy. Moreover, DCE-MRI shows potential in assessing response to antibiotic therapy in spinal infections. Dixon acquisition improves image quality and facilitates the detection of bone marrow abnormalities, aiding in the differentiation of diabetic foot from osteomyelitis. It also assists in distinguishing osteomyelitis from neuropathic arthropathy and provides valuable information in evaluating the diabetic foot. Proton MR spectroscopy, a well-established modality, offers metabolic information that can differentiate malignant from benign lesions.

Conclusions

The role of advanced MRI techniques in evaluating osteomyelitis remains to be fully defined, and further research is required to explore its potential utility in this context. In conclusion, the incorporation of advanced MRI sequences has shown promise in improving the differential diagnosis of osteomyelitis. Future investigations exploring combinations of these techniques and their clinical applications hold significant potential to enhance diagnostic accuracy and patient outcomes.

What's New in Pediatric Septic Arthritis? A Review of Pertinent Clinical Questions

BACKGROUND

The evaluation and treatment of children with septic arthritis (SA) is challenging and requires an organized approach to address the spectrum of pathogens which appear to aggregate in age-specific groups. Although evidence-based guidelines have recently been published for the evaluation and treatment of children with acute hematogenous osteomyelitis, there is a relative dearth of literature devoted exclusively to SA.

METHODS

Recently published guidance for the evaluation and treatment of children with SA was reviewed and evaluated with respect to pertinent clinical questions to summarize what is new in this area of practice for pediatric orthopaedic surgeons.

RESULTS

Evidence suggests that there is a profound difference between children with primary SA and those who have contiguous osteomyelitis. This disruption of the commonly accepted paradigm of a continuum of osteoarticular infections has important implications in the evaluation and treatment of children with primary SA. Clinical prediction algorithms have been established to help determine the applicability of magnetic resonance imaging during the evaluation of children suspected to have SA. Antibiotic duration for SA has been recently studied with some evidence in favor of short-course parenteral followed by short-course oral therapy may be successful if the pathogen is not methicillin-resistant Staphylococcus aureus .

CONCLUSION

Recent studies of children with SA have provided better guidance for evaluation and treatment to improve diagnostic accuracy, processes of evaluation, and clinical outcomes.

LEVEL OF EVIDENCE

Level 4.

[Septic arthritis and transient synovitis of the hip]

CLINICAL/METHODICAL ISSUE

Differentiating between septic arthritis and transient synovitis can be challenging but is very important as a late diagnosis of septic arthritis can lead to sepsis and joint damage. For correct diagnosis and prediction of complications, the right combination of physical examination, laboratory and radiological studies is needed.

STANDARD RADIOLOGICAL METHODS

Hip ultrasound is easy to learn and has a high sensitivity for joint effusion. Faster diagnosis and therapy are possible due to increasing use of ultrasound. Magnetic resonance imaging (MRI) is primarily used to rule out co-infections (osteomyelitis, pyomyositis) and differential diagnoses. X‑ray is typically nonremarkable in septic arthritis.

PRACTICAL RECOMMENDATIONS

Routine use of ultrasound in nontraumatic pediatric hip pain. Generous use of MRI in case of elevated inflammatory markers or inconclusive clinical findings. Using only few sequences may be appropriate to avoid sedation, primarily fluid sensitive sequences (fat-saturated T2, TIRM, STIR), in case of positive findings, accompanied by T1-weighted images.

Acute musculoskeletal infection in children: assessment and management

Musculoskeletal infection in children is challenging to treat, and includes septic arthritis, deep tissue infection, osteomyelitis, discitis and pyomyositis. Delays to diagnosis and management, and under-treatment can be life-threatening and result in chronic disability. The British Orthopaedic Association Standards for Trauma include critical steps in the timely diagnosis and management of acute musculoskeletal infection in children, the principles of acute clinical care and the service delivery requirements to appropriately manage this cohort of patients. Orthopaedic and paediatric services are likely to encounter cases of acute musculoskeletal infection in children and thus an awareness and thorough understanding of the British Orthopaedic Association Standards for Trauma guidelines is essential. This article reviews these guidelines and associated published evidence for the management of children with acute musculoskeletal infection.

Pitfalls of Diffusion-Weighted Imaging: Clinical Utility of T2 Shine-through and T2 Black-out for Musculoskeletal Diseases

Diffusion-weighted imaging (DWI) with an apparent diffusion coefficient (ADC) value is a relatively new magnetic resonance imaging (MRI) sequence that provides functional information on the lesion by measuring the microscopic movement of water molecules. While numerous studies have evaluated the promising role of DWI in musculoskeletal radiology, most have focused on tumorous diseases related to cellularity. This review article aims to summarize DWI-acquisition techniques, considering pitfalls such as T2 shine-through and T2 black-out, and their usefulness in interpreting musculoskeletal diseases with imaging. DWI is based on the Brownian motion of water molecules within the tissue, achieved by applying diffusion-sensitizing gradients. Regardless of the cellularity of the lesion, several pitfalls must be considered when interpreting DWI with ADC values in musculoskeletal radiology. This review discusses the application of DWI in musculoskeletal diseases, including tumor and tumor mimickers, as well as non-tumorous diseases, with a focus on lesions demonstrating T2 shine-through and T2 black-out effects. Understanding these pitfalls of DWI can provide clinically useful information, increase diagnostic accuracy, and improve patient management when added to conventional MRI in musculoskeletal diseases.