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Premium member Presentation Transcript Brodie’s Abscess: : Brodie’s Abscess: Subacute Osteomyelitis PHT 6403E: Imaging for Physical and Occupational Therapists Jennifer Nuce Sarah Manuel Sandra Schultz June 10, 2012Introduction: Introduction Brodie’s Abscess is a distinct form of subacute osteomyelitis; an abscess of bone surrounded by dense fibrous tissue and sclerotic bone. 1 Specifically, this disease is characterized by accumulation of the pathogenic organisms in the terminal arterioles and capillaries of the bone’s metaphysis . 2 The pressure from the edema and an increase in granulation will spark the bone necrosis thus forming a “ Brodie’s abscess.” 2 This disease has an insidious onset, mild local symptoms (typically nocturnal), few or no constitutional symptoms, and lacks a systemic reaction, and supportive laboratory data (normal values) are inconsistent. 1,3 Most commonly seen in children, specifically boys (3 boys:1 girl) at metaphyseal locations before the closure of growth plates. 4 With older adolescents, there is a possibility of epiphyseal lesions (failing to provide a barrier to the epiphysis). 4Signs and Symptoms: Signs and Symptoms In the acute phase of osteomyelitis: "The first and most significant symptom the afflicted child experiences is severe and constant pain near the end of the involved long bone.“ 5 “This is accompanied by exquisite local tenderness and the child’s unwillingness to use the limb." 5 “Within 24 hours the associated septicemia is evidence by malaise, anorexia, and fever; the child appears acutely ill." 5 Soft tissue swelling, is a relatively late sign appearing only after a few days and indicating the infection has already spread beyond the confines of the bone." 5 In the chronic stage of osteomyelitis : "The child having recovered from septicemia of the acute phase is no longer acutely ill but has a residual painful lesion in the involved long bone associated with swelling, tenderness, and loss of function of the limb, there may be one or more draining sinuses." 5 Frequently disease is misdiagnosed and has been commonly thought to be a primary bone tumor (e.g. osteoid osteoma) as both malignant and benign. 1,4 Local symptoms can be alleviated by aspirin.Location of typical Brodie’s Abscess: Location of typical Brodie’s Abscess The location of the abscess is usually at the metaphysis of tubular bones, along with carpal and tarsal bones. 3 Other possible locations are the pelvis, the vertebrae, the calcaneus, the clavicle, and talus. 4 Most common location is at the proximal/distal tibia metaphysis 4 ; followed by the femur. In general, the lower extremity is affected more often than upper extremity.Diagnosis and Prognosis: Diagnosis and Prognosis Diagnosis Usually difficult to diagnose because the characteristic signs and symptoms of the acute (osteomyelitis) form of the disease are absent. 1 Diagnosis can be prolonged from 1 month to 2 years. 4 Prognosis After diagnosing Brodie’s disease appropriately, the prognosis is good due to the disease being curable and with a 100% cure rate. 4 Patients are initially treated with two days of intravenous antibiotics and then were switched to oral antibiotics to complete a six week course. 2Impact to Functioning: Impact to Functioning The disease will impact normal functioning of his or her limb and their gait cycle will depict minimal loss of function (with the presence of a protective guarding to the limb). There will be a shorter unilateral weight bearing moments in the gait cycle of the involved extremity. The patient will usually depict a painful gait posture. Specifically, “pain behaviors” will be present.Complications: Complications Brodie’s Abscess can lead to various complications such as: 5 Joint contractures Pathological fractures Amyloid disease Malignant changes in epidermis (epidermoid carcinoma)Best Imaging Modality: Best Imaging Modality Plain Film Radiograph Conventional radiographs should always be the first step in imaging of a Brodie’s abscess. 5 Radiography is also valuable as a primary imaging technique as it can exclude other diagnoses and to monitor therapy. 5 Magnetic Resonance Imaging (MRI) Is the most sensitive technique to evaluate a Brodie’s abscess Nuclear Bone Scan a more sensitive test for detecting early disease Bone scintigraphy Is rarely indicated unless the diagnosis is unclear and a bone scan is performed as part of a tumor work-up. 5 Might be helpful for the assessment of multifocal subacute osteomyelitis. 5 Computed Tomography (CT) Is valuable in detecting lesions in difficult anatomic locations and to differentiate a Brodie’s abscess from osteoid osteoma. 5 Is also superior to conventional radiography or MR imaging for the detection of a sequestrum. 5Role of Imaging in Diagnosis and Management: Role of Imaging in Diagnosis and Management Imaging plays an important role in the diagnosis of Brodie’s abscess. It is hard to determine anything in the first days on onset but it is crucial to detect the infections to prevent further infection and problems, leading to increased dysfunction. According to Salter there are various ways to use imaging: " Only after the first week does the radiograph reveal the first evidence of destruction of bone in the metaphysis and the first signs of reactive new bone from the periosteum . “ 5 "During the first week before radiographic changes become apparent, scintigraphy (bone scan) may be of value in establishing the diagnosis. MRI, using the combination of dark focus on T1-weighted images and a bright signal on T2 weighted images is consistent with osteomyelitis." 5 "In the process of draining, a sinogram often helps locate the site of underlying infection." 5 “The radiographic diagnosis is usually apparent, particularly in the presence of obvious sequestra, nevertheless, the combination of local rarefaction, sclerosis, and periosteal new bone formation may mimic other bone lesions such as osteosarcoma, Ewing's sarcoma, and Langerhans cell histiocytosis (eosinophilic granuloma )." 5 “The radiographic appearance of a Brodie's abscess is not unlike that of an osteolytic bone neoplasm." 5Radiologic Classification: Radiologic Classification In 1973, Gledhill proposed a radiologic classification for primary subacute osteomyelitis Type I – Solitary lesion with surrounding sclerosis, classic Brodie abscess Type II – Metaphyseal radiolucent lesion with an associated loss of cortical bone Type III – Diaphyseal cortical hyperostosis without onion-skinning Type IV – Diaphyseal lesions associated with onionskin layering http://emedicine.medscape.com/article/1248682-overview#a0101Radiologic Classification: Radiologic Classification In 1982, Roberts et. a l., modified and expanded Gledhill's classification to 6 forms : Type I is metaphyseal. Type Ia is a punched-out central metaphyseal lesion. Type Ib is an eccentric metaphyseal cortical erosion. Type II is diaphyseal. Type IIa is a localized cortical and periosteal reaction. Type IIb is a medullary abscess in the diaphysis without cortical destruction but with onionskin periosteal reaction. Type III is epiphyseal. Type IIIa is a primary epiphyseal osteomyelitis. Type IIIb is a lesion that crosses the epiphysis and involves both the epiphysis and the metaphysis. Type IV is a metaphyseal equivalent. Type IVa involves the vertebral body with an erosive or destructive process. Type IVb involves the flat bones of the pelvis. Type IVc involves the small bones, such as the tarsal bones. http://emedicine.medscape.com/article/1248682-overview#a0101Presentation of Image – Conventional Radiographic Image: Presentation of Image – Conventional Radiographic Image http://radiopaedia.org/articles/brodie-abscess-1Radiographic Findings: Radiographic Findings Our radiograph of the tibia demonstrates a classic Brodie abscess – a solitary lesion with surrounding sclerosis and more specifically a Type Ia as a punched-out central metaphyseal lesion. There is an oval shaped lytic located on the anterior proximal tibia just medial to tibial tuberosity (actually a lateral view would be needed to confirm location). There is a thick dense rim of reactive sclerosis surrounding the lesion with a central radiolucency . There is no serpentine sign or tract seen in this radiograph. Typically you would see over time the abscess progressively elongate from epiphysis through the metaphysis, aka the “serpentine sign.” Alignment – the general skeletal architecture shows the normal size of the femur, tibia and fibula with no supernumerary or absent bones. The general contour of the femur, tibia, and fibula is smooth and continuous with no fractures noted. The alignment between the femur, tibia, and fibula show normal joint articulation and spatial relationship with no subluxation or dislocation noted. Bone Density – the general bone density shows sufficient contrast between soft tissue and bone and between the cortical and cancellous bone; normal trabecular architecture the exception of the lesion showing a rim of sclerosis with a radiolucent center. There is noted sclerosis at medial and lateral tibial plateau on the weightbearing surface. Cartilage spaces – the joint space width with well preserved and equal; the subchondral bone appears smooth at the femur and tibia; the epiphyseal plates are of normal size. Soft tissues – the muscles appear to be of normal size with no obvious wasting or swelling; the joint capsule appears normally indistinct with no effusion or hemorrhage noted; the periosteum also appears normal indistinct; no foreign bodies, gas bubbles, or calcifications are evident in the soft tissuesPresentation of Image – Magnetic Resonance Image (MRI): Presentation of Image – Magnetic Resonance Image (MRI) http://www.rbrs.org/dbfiles/journalarticle_0737.pdfMRI Findings: MRI Findings The previous slide shows 3 coronal MRIs of the same ankle. The far left is a T1-weighted, the middle one is a T2-weighted with fat suppression, and the far right image is a post-gadolinium T1-weighted images with fat suppression. Each image shows the Brodie’s abscess in the distal posterior aspect of the tibia. On the far left T1 weighted image, you can see the low signal intensity sclerotic rim and the moderate signal intensity central area. On the far right T1 weighted image, you can see the moderate signal intensity of the penumbra sign (a peripheral zone of higher signal intensity. Bone marrow edema is also present with its low signal intensity on the T1 and high signal intensity on the T2 weighted image.Brodie’s Abscess Questions : Brodie’s Abscess Questions 1) As a physical therapist, how would the possible biomechanical dysfunctions impact the patient’s intervention? 2) Brodie’s abscess is seen as a subacute osteomyelitis. What would imaging show in the acute phase of osteomyelitis?References: References 1. Khoshhal K, Letts RM, Mehlman CT. Subacute Osteomyelitis ( Brodie Abscess). Medscape Reference. Available at: http://emedicine.medscape.com/article/1248682-overview#a0101 . Accessed June 7, 2012. 2. Gaillard F, et al. Brodie abscess. Radiopaedia.org. Available at: http://radiopaedia.org/articles/brodie-abscess-1. Accessed June 8, 2012. 3. Brodie's Abscess (SUBACUTE EPIPHYSEAL OSTEOMYELITIS). E-Radography.net. Available at: http://www.e-radiography.net/radpath/b/brodies_abscess.htm . Accessed June 8, 2012. 4. Kornaat PR, Camerlinck M, Vanhoenacker , FM, et al. Brodie’s abscess revisted. Journal Belge de Radiologie - Belgisch Tijdschrift voor Radiologie. 2010;93:81-86. 5. Salter RB. Textbook of Disorders and Injuries of Musculoskeletal System . Philadelphia, PA: Lippincott, Williams and Wilkins; 1999. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.