Emergency Radiology

, Volume 25, Issue 2, pp 175–188 | Cite as

Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection

  • Jacob C. Mandell
  • Bharti Khurana
  • Jeremy T. Smith
  • Gregory J. Czuczman
  • Varand Ghazikhanian
  • Stacy E. Smith
Review Article


Osteomyelitis is inflammation of the bone caused by an infectious organism, and is a difficult clinical problem. The pathophysiology, imaging, and classification of osteomyelitis are challenging, varying with the age of the patient (child versus adult), the chronicity of the infection (acute versus chronic), and the route of spread (hematogenous versus contiguous focus), as well as the immune and vascular status of the patient and affected region. The two most common classification schemes are those of Lew and Waldvogel, and Cierny and Mader. Brodie’s abscess is seen in subacute osteomyelitis, while sequestrum, involucrum, and cloaca are inter-related entities of chronic osteomyelitis. Imaging workup of suspected osteomyelitis should begin with radiographs, although MRI is the most accurate imaging test. Three patterns of T1 signal change have been described in the setting of suspected osteomyelitis including confluent intramedullary, hazy reticular, and subcortical. The confluent intramedullary pattern is most associated with osteomyelitis, while hazy reticular is rarely associated with hematogenous osteomyelitis, and subcortical is not associated with osteomyelitis. It can be challenging to differentiate neuropathic arthropathy from osteomyelitis. Osteomyelitis tends to involve a single bone subjacent to an ulcer or sinus tract. In contrast, neuropathic arthropathy tends to involve multiple bones of the midfoot. Subchondral cystic change, thin rim enhancement of a joint effusion, and the presence of intra-articular bodies are more indicative of a neuropathic joint without infection. Biopsy can play an important role in diagnosis and treatment of osteomyelitis.


Osteomyelitis Lower extremity Foot and ankle Neuropathic arthropathy Diabetic foot infection 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© American Society of Emergency Radiology 2017

Authors and Affiliations

  1. 1.Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  2. 2.Division of Emergency Radiology, Department of Radiology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  3. 3.Department of Orthopedic Surgery, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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