Osteomyelitis: temporal change including sequestrectomy

Case contributed by Rodney Strahan
Diagnosis certain


10 year old boy presented with tender right lower limb and fever.

Patient Data

Age: 10 years old
Gender: Male

Presentation x-ray


Initial radiographs are normal.

Manifestation of infection in bone is late for plain films.

Three weeks from presentation


3 weeks post presentation, there is a permeative process involving the proximal and distal metaphysis of the tibia. In addition, early periosteal reaction along the tibia is present. Given the presentation and earlier normal images, this would indicate osteomyelitis of the tibial shaft.

Importantly, the growth plates do not seem to be involved.

Two months from presentation


2 months post presentation, with ongoing antibiotic treatment, the periosteal reaction is forming an involucrum around a developing sequestrum, which was the original tibial shaft.

Five months post presentation


5 months post presentation, and still on antiobiotics, the involucrum has formed a solid case around the sequestrum. However the sequestrum is still a potential source of infection and needs to be removed. The involucrum is firm enough to allow this to happen and for the patient not to have an unstable leg.

The tibia is still growing at the proximal and distal growth plates and the leg is not shortened (the fibula is not bowed).

Post sequestrectomy (removal of dead bone).

Case Discussion

This is a typical case of osteomyelitis with the initial radiographs normal, progressing to chronic changes with a sequestrum and involucrum. 

Sequestrum is dead bone that has become separated during the process of necrosis from normal bone. This is especially seen distally. Involucrum is a covering or sheath, and contains the sequestrum of a necrosed bone.

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