Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

Current Problems in Diagnostic Radiology

journal homepage: www.cpdrjournal.com

Pediatric Skeletal Scintigraphy: What a General Radiologist Needs

to Know
Fathima Fijula Palot Manzil, MBBS, DMRT, ABNM Board Certifieda,b,c,n, Jon Baldwin, DOa,
Asim Kumar Bag, MDd
a
Division of Molecular Imaging and Therapeutics, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
b
Department of Clinical Radiology, Weill Cornell Medical College in Qatar, Education City, Qatar
c
Nuclear Medicine and PET-CT Section, Department of Radiology, Hamad General Hospital, Doha, Qatar
d
Neuroradiology Section, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL

Pediatric skeletal scintigraphy is a noninvasive imaging modality which aids in functional as well as anatomic evaluation of bone. Bone scintigraphy plays a
major role in diagnosis and evaluation of various benign, primary malignant and metastatic pediatric bone pathologies. The advantage of bone scan is that it
becomes positive well before the bone pathology is evident on radiographs and specifically the entire skeleton can be imaged in a single examination.
Pediatric bone scintigraphy evaluation can be challenging to the general radiologist not routinely exposed to the study, as the growing skeleton is quite
different from a mature skeleton especially at or near the growth plates. Though nonspecific, bone scintigraphy is a very sensitive modality. Correlation with a
good history and other imaging modalities like radiographs, computed tomography and magnetic resonance imaging helps in diagnosis.
& 2017 Elsevier Inc. All rights reserved.

Introduction An essential requirement in children is to decrease radiation

Pediatric skeletal scintigraphy (PSS) is one of the most common
indications for radionuclide examinations in children. Interpreta-
tion of PSS can be challenging as it requires knowledge of the
normal appearances of the maturing skeleton. PSS is a highly
sensitive study to identify alterations in bone metabolism from any
cause. Imaging of the entire skeleton can be obtained with same
radiation burden and is relatively easy to perform. Challenges of
PSS include low specificity, relatively long acquisition time, and
difficulty of immobilizing young children.
Physiology and Technical Considerations
The bony skeleton is a highly dynamic organ that maintains a
normal bone mass through a homeostasis mechanism between bone
resorption (osteoclastic activity) and bone formation (osteoblastic
activity).1 This homeostasis can change during the normal physiolog-
ical process of growth and remodeling and in response to pathological
processes. Osteoblastic activity is performed by osteoblasts, which
form osteoid matrix that ultimately mineralizes with hydroxyapatite.
Currently used radiopharmaceuticals adsorb to the hydroxyapatite
crystal.2 Any process that alters the homeostasis with relative increase
in bone formation results in high radiopharmaceutical uptake.
n
Reprint requests: Fathima Fijula Palot Manzil, MBBS, DMRT, ABNM Board
Certified, Nuclear Medicine and PET-CT Section, Department of Radiology, Hamad
General Hospital, PO Box 3050, Doha, Qatar.
E-mail address: drfijulasurjith@yahoo.com (F.F. Palot Manzil).
exposure to possible minimum without compromising image quality.
The Image Gently Campaign is an initiative of the alliance for
radiation safety in pediatric imaging.3 Selection of radiopharmaceut-
ical dosage and imaging technique on case-by-case basis is impor-
tant.4 During image acquisition, the child has to lie still; general
anesthesia or light sedation may be used for certain examinations and
cooperative parents are a great help. For newborns and small
children, it is ideal to arrange the delayed images in the usual
sleeping time of the day. For older children, pleasant surroundings,
entertainment during imaging, and appropriate attitude and
approach toward the child help for better immobilization. All imaging
should be performed with the child lying down. When using dual-
head gamma camera system, the posterior head should be placed as
near as possible to the child. The child might get terrified if the
anterior head is placed too close.5 For imaging of hands and elbows,
the child can place the extremity directly over the collimator. Flow
and blood pool images are obtained for selected patients. Routinely,
delayed, planar whole-body images are obtained in anterior and
posterior views 2-5 hours after radiotracer injection. Specific spot
images are obtained as per the indication of the test.
Single photon emission computed tomography (SPECT) imag-
ing gives the added benefit in determining the presence, location,
and extent of some diseases, such as acute pars fracture, which are
challenging on the planar image. Performing low-dose computed
tomography (CT) along with SPECT can help with attenuation
correction, anatomical localization, and at times better diagnosis.
Use of SPECT or SPECT/CT in pediatric patients should always be
justified and be strictly limited to the body part of interest.
Purpose of the CT part must be clear before performing the scan.
If high-resolution images are required, imaging using pinhole

http://dx.doi.org/10.1067/j.cpradiol.2017.07.001
0363-0188/& 2017 Elsevier Inc. All rights reserved.
2 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

FIG. 1. (A) A 4-month-old child with fever of unknown origin. Planar blood pool phase sequential images in anterior (upper row) and posterior (lower row) projections
demonstrate normal physiological activity in blood pool (heart: horizontal white thin arrow), soft tissue (liver: horizontal thin black arrow, spleen: horizontal thick black
arrow), urinary system (kidneys: oblique thin black arrows, urinary bladder: oblique thin white arrow), and skeletal system (vertebrae: horizontal thick white arrow). (B) A
6-year-old child with history of trauma. Planar delayed phase bone scintigraphy images in anterior and posterior projections demonstrate physiological normal activity in the
skeletal system, kidneys (thin white arrows), and urinary bladder (thin black arrow). Note the intense normal uptake in growing physes (thick white arrows) in this young
child. (C) A 10-year-old patient with history of fall. Planar scintigraphic spot images of whole body in anterior and posterior projections demonstrate physiological activity in
the skeletal system, urinary bladder (white thin arrow), and growing physes (black thin arrows). Note the dose infiltration (thick black arrow) at the injection site in right
elbow. (D) A 16-year-old patient with back pain. Planar scintigraphic whole-body images in anterior and posterior projections show normal radiotracer distribution. Note
that there is no intense uptake at the physes as the physes are already fused in this adolescent patient. Physiological activity from radiotracer excretion is seen in kidneys
(black arrow) and urinary bladder (white arrow). (E) A 13-year-old boy with bilateral chest pain. Planar scintigraphic image of chest in anterior projection shows normal
increased radiotracer uptake in adolescent breast tissue (black arrows). (F) A 14-year-old boy with head injury. Planar scintigraphic image of skull in posterior projection
shows normal increased tracer uptake in occipital protuberance. (G) A 10-year-old girl with left lower leg pain. Planar scintigraphic image including right lower leg and foot
in lateral projection demonstrates normal increased tracer uptake in calcaneal apophysis (oblique white arrow). Note the physiological intense uptake in growing physis at
ankle joint (horizontal white arrow). (Color version of figure is available online.)

collimator can help for better delineation, especially if the ana-
tomical area of interest is small.
Radiopharmaceuticals
99m-Tc-Methylene diphosphonate is the most commonly used
radiotracer for skeletal scintigraphy. Uptake is dependent upon
local blood flow and degree of osteoblastic activity. Even a 5% bone
turnover can be detected by bone scan.6 99m-Tc-methylene
diphosphonate rapidly localizes in the skeleton. Excretion is
primarily renal, and 70% of the administered dose is eliminated
by 6 hours. Urinary bladder is the critical organ. Recommended
dose is 9.3 MBq/kg (0.25 mCi/kg) with a minimum dose of 37 MBq
(1 mCi) (North American Guidelines for Pediatric Nuclear
Medicine).
 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]] 3

TABLE nidus will be surrounded by reactive trabecular bone. Common

Factors causing altered biodistribution of radiotracer used in pediatric skeletal sites of involvement are femur (Fig. 2) and tibia. Common location
scintigraphy
in the spine is lumbar spine7 and almost always involves the
▪ High renal uptake posterior elements. The lesion is most commonly cortical, though
◆ Poor hydration it could be medullary or periosteal. Bone scintigraphy is very
◆ Use of nephrotoxic drugs sensitive and typically show increased activity in the flow, blood
◆ Nephrocalcinosis pool, and delayed images. Sometimes delayed images demonstrate
◆ Acute tubular necrosis
◆ Sickle cell disease
a focus of intense uptake in the nidus surrounded by an area of
◆ Hemochromatosis less intense uptake in the reactive bone (double-density sign).
▪ High muscle uptake Bone scintigraphy with a pinhole collimator is very helpful in
◆ Rhabdomyolysis accurate localization and aiding in surgical resection. Negative
◆ Myositis ossificans bone scan often excludes the diagnosis. Curative treatment
▪ High liver uptake is complete surgical removal. The symptoms recur if nidus is
◆ Recent bone marrow scan not completely removed. Sometimes osteoid osteoma may
◆ Excess Al3 þ
spontaneously regress.
◆ Amyloidosis
◆ Hepatic metastasis
▪ High stomach and thyroid uptake Fibrous Dysplasia. Fibrous dysplasia (FD) is a benign-tumor-like
◆ Free 99mTc technetium in the injection
congenital process, manifested as defect in osteoblastic
◆ High splenic uptake
◆ Sickle cell disease differentiation and maturation with progressive replacement of
◆ Metastasis normal medullary bone with fibrous tissue. It is usually seen in
◆ Hemosiderosis young adults. FD can be sporadic or associated with McCune
▪ Superscan (intense activity in the bones with absent or decreased activity in Albright syndrome (with endrocrinopathy) and Mazabraud
kidneys and soft tissues) syndrome (with soft tissue myxoma). The most common type is
◆ Widespread metastasis
monostotic form, which commonly occurs in femur, tibia,
◆ Osteomalacia
◆ Renal osteodystrophy or Secondary hyperparathyroidism
craniofacial bones (Fig. 3), and ribs, though can occur at any
bone. The polyostotic form tends to occur unilaterally.
Asymmetric bilateral involvement can also occur. The polyostotic
form commonly affects femur, tibia, and pelvis. Bone scintigraphy
typically shows markedly increased uptake in blood pool, and
Clinical Applications of PSS delayed images and is very helpful in evaluating the extent of bony
involvement. Bone scan also helps to evaluate complications of FD-
It is of utmost importance to know normal pediatric bone scan like fractures and to assess femoral head vascularity after a
pattern and physiological normal variants of radiotracer distribution fracture through FD in femoral neck.8
(Fig. 1). Altered biodistribution can be seen in various conditions
(Table). Common indications for PSS include the following conditions.
Malignant
Osteosarcoma. Osteosarcoma is the most common primary
Bone tumors malignant bone tumor in children, with maximum incidence at
adolescence and young adulthood. Frequent locations are distal
Benign femur (Fig. 4A) and proximal tibia though can occur at any bone
Osteoid Osteoma. Osteoid osteoma is a benign bone tumor of (Fig. 4B). It commonly affects metaphysis of long bones. Pelvic
unknown etiology, commonly seen in adolescents and young osteosarcoma (Fig. 4C) is rare (2.5%) and has poor prognosis
adults. It typically presents with focal bone pain, worse with compared to long bones. Lungs and bones are the common
activity and at night. Osteoid osteoma is composed of a central metastatic locations.7 Bone scan is helpful to identify skip
nidus usually less than 1.5 cm in diameter and is highly vascular. It lesions, distant metastasis, and thus for staging. Whole-body
is composed of osteoid, osteoblasts, and vascular channels. The baseline and further follow-up bone scans help to evaluate

FIG. 2. (A) A 13-year-old patient with left femur osteoid osteoma. Planar scintigraphic image from the level of pelvis to knees in anterior projection shows intense uptake at
left lateral mid femoral diaphysis (black arrow). (B) Axial section of CT scan at the level of mid-thigh shows lesion at lateral mid shaft of left femur with a central nidus (white
arrow), corresponding to the lesion on bone scan.
4 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

FIG. 3. (A) A 9-year-old patient with fibrous dysplasia. Planar scintigraphic image including calvarium and neck in lateral projection depicts increased tracer uptake in the
posterior wall of right orbit (black arrow). (B) CT scan section through the orbits shows expansion and ground-glass appearance in posterior wall of the right orbit (white
arrow) corresponding to the increased uptake on bone scan.

treatment response and tumor recurrence. As there is new osteoid typically show intense uptake. CT scan of chest is required to
formation in osteosarcoma, bone scan will show high uptake of identify pulmonary metastases, though bone scan sometimes
radiotracer in all 3 phases. Primary and metastatic osseous lesions show lung metastases due to osteoid produced by the

FIG. 4. (A) A 15-year-old patient with right femur osteosarcoma. Planar scintigraphic whole-body images in anterior and posterior projections show intense uptake at the
lower end of right femur (arrows) which is the typical location and appearance of osteosarcoma. (B) A 16-year-old patient with left clavicle osteosarcoma. Planar
scintigraphic whole-body bone scan in anterior and posterior projections depict intense uptake at the left clavicle (arrows), a rare site for osteosarcoma. (C) An 18-year-old
patient with osteosarcoma of the left ilium. Planar scintigraphic spot image of the pelvis in anterior and posterior projections shows intense heterogeneous uptake at the left
ilium (arrows). There was significant soft tissue component on MRI (not shown). (Color version of figure is available online.)
 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]] 5

FIG. 5. (A) A 10-year-old patient with left femur Ewing Sarcoma. Planar whole-body bone scan in anterior and posterior projections show high uptake along the left upper
femoral diaphysis (horizontal thin arrows). Note the predominant cortical involvement, a feature of the tumor seen as “onion-skin” appearance on radiograph (not shown).
There is dose infiltration at left antecubital fossa (oblique thick arrows). (B) An 11-year-old patient with Ewing Sarcoma of the left ilium. Planar scintigraphic spot image at
the level of hips depicts high uptake along the left ilium. (C) A 13-year-old patient with Ewing Sarcoma of right lower femur. Planar spot scintigraphic image at the level of
bilateral knees shows high uptake at the right lower femur (thick oblique black arrows). High uptake at right upper tibia (thin oblique black arrows) is due to local
hyperemia. Focal warm spots at bilateral medial lower thighs (horizontal thin black arrows) are due to contamination. (Color version of figure is available online.)

metastases.7 Magnetic resonance imaging (MRI) of the primary half of patients present with osseous metastasis.7 PSS is the
lesion should be done to assess the extent of soft tissue traditional test used to assess cortical bone metastases in
involvement. neuroblastoma and helps distinguish cortical bone from bone
marrow involvement. I-123 metaiodobenzylguanidine (MIBG)
scan may be superior to bone scan in detection of skeletal
Ewing Sarcoma. Ewing sarcoma is a malignant tumor of
metastasis, but is unable to differentiate cortical from marrow
mesenchymal origin and is the second most common primary
metastases. Either MIBG alone or MIBG and PSS are used to follow
bone malignancy in children. More than 80% of Ewing sarcoma
the patients. A bone scan is still typically performed at diagnosis
occur in patients under 20 years of age, with peak incidence at
for disease staging. However, high uptake on posttreatment bone
4-15 years. Boys are affected more than girls. The tumor usually
scans cannot distinguish active metastasis from bony repair as a
arises in the diaphysis of a long bone (Fig. 5A). Femur is the most
part of treatment response.7 Also, neuroblastoma metastases
common bone to be affected followed by tibia and humerus; 20% of
can symmetrically affect the metaphysis of long bones, making
Ewing sarcoma arises in the pelvis (Fig. 5B) and has worse
detection on bone scan difficult because of the adjacent
prognosis. The most common presentation is pain and swelling.
physiological uptake in the physis. Approximately 40%-85% of
Systemic symptoms such as fever, anorexia, weight loss, and fatigue
primary lesions of neuroblastoma demonstrate bone scan
can be confused with osteomyelitis (OM). Approximately 20% of
radiotracer uptake (Fig. 6). This chance of uptake by the primary
patients have metastatic disease at the time of initial diagnosis.
increases with tumor size and likely represents calcium
Lungs and skeleton are the most common sites of metastases.7
metabolism by the active tumor.9 Skeletal tracer uptake by the
Ewing sarcoma is typically hot in all phases of a three-phase
primary does not have any prognostic significance. If bone scan in
bone scan. Whole-body baseline and follow-up bone scans help in
a young child shows uptake within extraskeletal primary along
staging by identifying skip lesions and distant metastasis along
with multiple foci of abnormal skeletal uptakes, then the most
with primary lesion and also help assess treatment response and
likely diagnosis is neuroblastoma.
tumor recurrence. As the abnormal uptake often extends beyond
the exact pathologic boundaries due to hyperemia (Fig. 5C) in
osteosarcoma and Ewing sarcoma, PSS is not a good test to assess
Malignant-like
tumor margins.9 Skeletal scintigraphy is seldom the first study to
Langerhans Cell Histiocytosis. Langerhans cell histiocytosis is a
detect primary skeletal malignancies that are usually diagnosed by
group of idiopathic disorders characterized by proliferation of
radiography. Diagnostic radiographs and CT scans typically show
histiocytes in the reticuloendothelial system. The most common
destructive lytic lesion in the diaphysis of the bone. MRI helps to
manifestation is bony involvement. The most common areas of
assess the extent of soft tissue involvement.
involvement include skull, mandible, spine, pelvis, and ribs;
though it can occur at any bone.7 It could be asymptomatic or
Neuroblastoma (Nonskeletal). Neuroblastoma is a tumor of the symptomatic with pain and swelling. Eosinophilic granuloma is
sympathetic nervous system and is composed of neuroblasts. The the most common and benign form of Langerhans cell
most common site of neuroblastoma is adrenal gland. histiocytosis, predominantly affecting children and adolescents,
Neuroblastoma is the most common tumor in infancy. More than although can be found in any age. Solitary lesion is more common
6 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

FIG. 6. A 1.5-year-old patient with left abdominal neuroblastoma. Planar scintigraphic images including chest, abdomen, and pelvis in anterior and posterior projections
depict increased radiotracer uptake in the left abdominal mass (arrows).

than multiple lesions. Generally, the skeletal involvement is seen (Fig. 7A) or a photopenic center with or without a surrounding rim
as bone destruction. Bone scintigraphy is very sensitive for ribs, of intense activity7 (Fig. 7B). Increased, normal, or decreased tracer
spine, and pelvic lesions but is less sensitive for skull lesions. activity can be seen depending upon the residual or reactive bony
Typical appearance on bone scan is a focus of increased uptake cortex.

FIG. 7. (A) A 7-year-old patient with eosinophilic granuloma of the right femur. Planar scintigraphic images in anterior and posterior projections from the level of lower
thoracic spine to the knees depict right mid-femur uptake (arrows). (B) An 11-year-old patient with eosinophilic granuloma of the right parietal bone. Planar whole-body
bone scan in anterior projection depicts small photopenic area at right side of the skull (horizontal arrow). Increased activity at right antecubital fossa (oblique arrow) is from
dose infiltration.
 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]] 7

FIG. 8. (A) A 10-year-old patient with a history of osteosarcoma of the right femur (primary lesion not shown). Planar scintigraphic image in anterior projection including
calvarium and chest depicts increased radiotracer uptake at the right scapula (arrow) metastatic lesion. (B) A 13-year-old patient with Ewing Sarcoma of the right ilium (thick
oblique black arrows). Planar whole-body bone scan images in anterior and posterior projections show increased uptake in right-sided ribs (horizontal thin black arrow in
anterior projection), and a focal hot spot in right skull (oblique thin black arrow in posterior projection) suggestive of metastases. (Color version of figure is available online.)

Metastasis. The ability of PSS to recognize clinically and
radiographically occult osseous metastasis has made it an
important imaging modality to identify skeletal metastasis in
patients with known cancer. Baseline PSS helps in staging, and
follow-up PSS helps to assess treatment response of known bony
metastases. PSS is used to assess pediatric metastatic disease
commonly in cases of osteosarcoma (Fig. 8A) and Ewing
sarcoma9 (Fig. 8B). Bone scan is crucial in a child with known
cancer who presents with radiographically negative bone pain.
Osseous metastases are often seen as foci of increased uptake.
Skeletal scintigraphy is not routinely performed owing to reduced
sensitivity in malignancies that involve bone, which manifest with
aggressive and osteolytic lesions. Low or normal uptake may be
seen in such cases. Metaphyseal metastases can be sometimes
missed owing to adjacent normal physeal uptake. Extraskeletal
metastases that can sometimes be detected on bone scan include
pulmonary metastasis from osteosarcoma and hepatic and other
extraskeletal metastases from neuroblastoma.9
Infections
Osteomyelitis
OM is infection of bone caused by bacteria or other organisms.
The most common causative pathogen is Staphylococcus aureus.
The most common cause is hematogenous spread from another
body part, although direct spread from adjacent infected body
parts and postsurgery are other causes. It most commonly affects
children less than 5 years; though it can occur at any age and
usually involves metaphysis of long bones (Fig. 9A). In small
children, septic arthritis of adjacent joint is a possibility, whereas
growth plate can serve as a barrier for septic arthritis in older
children.7 Clinical findings include pain, swelling, erythema,
warmth, fever, and refusal to bear weight.
The use of bone scan vs MRI for the diagnosis and evaluation of
OM is practice dependent. The diagnosis is made by constellation of
findings from laboratory investigations including complete blood
count, C-reactive protein, erythrocyte sedimentation rate and blood
culture, bone scintigraphy or MRI, and radiographs. PSS is highly
sensitive for the diagnosis of OM and usually is positive well in
advance compared to radiograph. PSS has sensitivity and specificity
of approximately 95% in diagnosing acute OM. Children with typical
symptoms and positive radiographs do not require further imaging.
Typical radiographic finding of radiolucency of the affected bony
region and periosteal new bone are not seen for 7-10 days after the
onset of infection.10 If there is doubt about the clinical diagnosis or
exact focus of infection as in cases of referred pain, bone scan helps
in diagnosing and localizing the disease before surgery.
A 3-phase bone scan involving immediate blood flow and blood
pool phases and delayed osseous phase of the concerned region is
performed for evaluation of OM. Focal increased activity is mostly
seen in all 3 phases (Figs 9B-D). Hyperemia may sometimes be
absent and just delayed image could be positive in cases of
compromised local vascular supply secondary to subperiosteal
abscess or edema, intramedullary abscess, joint effusion, and vaso-
spasm. Photopenic defect on delayed image may be seen in some
cases secondary to increased intraosseous pressure, vascular throm-
bosis, or vascular compression caused by bone marrow edema11
(Fig. 9E). False-negative bone scan is rare but can be seen in the
transition phase from low-to-high uptake. In suspicious cases, the
bone scan should be repeated. Hyperemia of infection may cause
increased uptake in adjacent growth plate, which could be confused
for an additional focus of infection. Normally, the growth plate has a
linear configuration and gets distorted if pathologically involved.8
Whole-body scan should be performed in the delayed phase as OM
in children can be multifocal. A positive bone scan almost always
confirms the diagnosis of OM, whereas a negative scan does not rule
out OM. In such cases, further imaging with tagged white blood cell
scan, ultrasound, or MRI should be performed.8 Bone scan can be
positive in up to 2-3 years after successful treatment. In chronic OM,
symptoms may come and go for years even after surgery and may
result in amputation.
8 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

FIG. 9. (A) A 11-year-old patient with osteomyelitis of the left femur. Planar scintigraphic whole-body images in anterior and posterior projections show intense radiotracer
uptake in the lower aspect of left femur including epiphyseal, metaphyseal, and diaphyseal regions. (B-D) A 11-year-old patient with right femur osteomyelitis. (B) Dynamic
flow phase images in anterior projection at the level of knees show increase uptake at lower aspect of right thigh (arrow). (C) Blood pool phase images in anterior and
posterior projections at the level of knees show increase uptake in the lower aspect of right femur and adjoining area (thin arrows). Small photopenic area (thick arrows)
seen at the center of region of increase uptake is due to an abscess. (D) Planar whole-body delayed images in anterior and posterior projections show heterogeneous
increased uptake in the right femur metaphysis (thin arrows) extending to adjacent diaphysis. Photopenia (thick arrows) at the center of heterogeneous uptake is due to an
abscess. (E) A 10-year-old patient with osteomyelitis of right tibia. Planar scintigraphic whole-body images in anterior and posterior projections show focal photopenia at the
upper third of the right tibia (arrows) without any increased uptake. Note that this appearance of photopenia in osteomyelitis is not uncommon in children but rare in adults.
(Color version of figure is available online.)

MRI is highly sensitive in detecting OM. The fact that
performing whole-body MRI is not always practical and children
under 5 years often need to be sedated to perform MRI scanning
makes skeletal scintigraphy a valuable test in evaluation of
OM, especially in cases of negative radiographs and poorly
localized symptoms.12 MRI is the relevant test when evaluating
spine or pelvis or in cases where abscess formation is suspected.10
knee are commonly involved, and the frequent type is the mono-
articular form. Symptoms include pain, fever, swelling, and redness
of the joint. Pain with passive motion is a consistent finding in septic
arthritis.7 On PSS, joints affected by septic arthritis show increased
periarticular activity on any or all phases. Decreased or absent tracer
activity may be seen in femoral capital epiphysis in cases of septic
arthritis involving the hip due to compression of intracapsular
vessels by effusion and usually normalizes after arthrocentesis.10

Septic Arthritis Aseptic Necrosis

It is most common in less than 3 years of age and usually caused
by S. aureus. Causes of septic arthritis include hematogenous Legg-Calvé-Perthes Disease
seeding of organisms through the synovium, spread from acute OS It is an idiopathic ischemic necrosis of the femoral head, most
involving intra-articular bone, or direct puncture wounds.10 Hip and common in children between 5 and 8 years of age. The symptoms
 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]] 9

include pain and limping and are usually unilateral. Poor prog-
nostic indicators include older age and involvement of entire
femoral head.13 Better outcome is seen in children o 6 years and
could be due to better chance for bone remodeling. Radiographs
and ultrasound are the imaging approaches for pediatric hip pain.
If they are inconclusive, a bone scan should be done. Bone
scintigraphy is more sensitive than radiography for early diagnosis.
Pinhole images can improve resolution. Typically, earlier bone scan
done at the onset of symptoms shows absent activity in the
involved capital femoral epiphysis. Reactive increased uptake will
often be seen in the metaphysis. Bone scan findings appear much
before radiographs become positive. Later scans may exhibit
increased activity from revascularization and remodeling. Bone
scan can help differentiate patients with better and poor outcome.
Continued absent radiotracer activity in the femoral head even
after 5 months or increased activity in the metaphysis is associated
with more severe disease and bad prognosis.7 The early appear-
ance of a rim of activity in the capital femoral epiphysis due to
early revascularization is a good prognostic indicator. Thus, bone
scan is a useful adjunct to categorize the outcome of patients. Mild
forms can be treated conservatively, whereas surgery is the option
for advanced cases.
Sickle Cell Disease
Sickle cell disease is an autosomal recessive hemoglobinopathy.
Musculoskeletal manifestation is the commonest presentation and

FIG. 10. A 9-year-old patient with sickle cell disease. Planar whole-body bone scan images in anterior and posterior projections show focal uptake in the left upper abdomen
superior to left kidney, best seen on posterior projection (arrow). This is uptake in the small-sized infarcted spleen. Normal physiological activity is seen in kidneys.
Photopenia in the mid-thoracic vertebrae is from laminectomies done to treat epidural abscesses (thick arrow).
10 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]

cause of morbidity. Bone complications of sickle cell disease Steroid Use

include vaso-occlusive crisis, OM (most common cause is Salmo-
nella species), stress fractures, orbital compression, vertebral
collapse, bone marrow necrosis, osteonecrosis, chronic arthritis,
osteoporosis, and impaired bone growth. Microvascular emboliza-
tions are the cause for skeletal crisis. Painful crisis usually occurs at
metadiaphyseal region and can affect multiple sites. Secondary
infections such as OM or septic arthritis occur as these patients are
usually immunocompromised. Steroid exposure can lead to osteo-
necrosis.14 Bone scintigraphy usually has multiple abnormal foci of
radiotracer uptake from multiple bone infarctions. A 99mTc-sulfur
colloid bone marrow scan in conjunction with bone scan helps in
disease evaluation. Early in the event of vaso-occlusive crisis, if the
location of pain show abnormal uptake on bone marrow scan
along with normal or decreased uptake on bone scan, most likely
diagnosis is infarction. However, high uptake on bone scans,
especially if positive on all 3 phases, is more suggestive of OM.7
Splenic uptake could be seen on bone scan of sickle cell disease
due to autosplenectomy or splenic infarct (Fig. 10).
Possible mechanisms by which avascular necrosis is caused by
chronic glucocorticoid use include fat emboli, fat hypertrophy, and
intravascular coagulation affecting bone perfusion.15
Trauma
Bone scintigraphy is very sensitive and become abnormal
within few hours following injury. Hence, bone scan is very helpful
in diagnosing and localizing occult injuries well before the radio-
graphs become positive.
Spondylolysis
Spondylolysis is stress fracture of pars interarticularis of the
vertebrae. It commonly occurs in lower lumbar spine from
repetitive minor trauma. It usually presents as acute or chronic
back pain in a young athlete. Congenital weakness of the pars from
various hereditary factors also has a role in pathogenesis.

FIG. 11. (A) A 12-year-old patient with bilateral spondylolysis. Planar scintigraphic images including lumbar spine and pelvis in anterior and posterior projections show
subtle increased activity at the left lateral aspect of L5 on posterior projection (arrow). (B) A 12-year-old patient with bilateral spondylolysis. Axial (upper image) and coronal
(lower) SPECT reformatted images of the same patient demonstrate high uptake at bilateral L5 pars interarticularis (arrows) consistent with pars defects (spondylolysis).
 F.F. Palot Manzil et al. / Current Problems in Diagnostic Radiology ] (2017) ]]]–]]]
FIG. 12. (A-C) A 14-year-old patient with reflex sympathetic dystrophy of the left hand. Blood flow, blood pool, and delayed phases of three-phase bone scan of bilateral
hands and wrists demonstrate increased periarticular radiotracer activity of left hand in all phases.
Though pars defects can be imaged with plain radiography, CT,
and MRI, bone scintigraphy gives the diagnosis much earlier.
Generally, there will be high focal uptake in the region of the pars
interarticularis (Fig. 11A) if there is spondylolysis. SPECT imaging is
more sensitive than planar studies. In one-third of patients where
planar imaging is negative, SPECT can identify the abnormality7
(Fig. 11B). Hence, SPECT is always recommended in young athletes
who present with low back pain, especially if the planar images
are noncontributory to rule out spondylolysis. Bilateral spondylol-
ysis may cause spondylolisthesis.
Reflex Sympathetic Dystrophy or Complex Regional Pain Syndrome
Acute or remote trauma is the common triggering factor for
reflex sympathetic dystrophy (RSD). Neurologic disease is yet
another precipitating factor. RSD is a chronic pain syndrome often
characterized by other symptoms as well such as swelling, vaso-
motor disturbances, and trophic dermal changes. Negative clinical
and laboratory findings in a child with chronic pain should arouse
suspicion of RSD.7 Radiographic findings are nonspecific. Three-
phase bone scintigraphy has a sensitivity and specificity of 490% in
the diagnosis of RSD. Duration of symptoms for o6 months
increase the sensitivity and positive predictive value of bone scan.16
The typical findings on bone scan are diffuse increased perfusion
to the entire extremity (Fig. 12A), even when the inciting lesion is
distal. Blood pool and delayed images also show diffuse increased
activity in the affected extremity with intense periarticular activity
(Fig. 12B and C). Activity in the hands or feet usually is more
prominent proximally than distally. There are reports of cold variant
of RSD where there is decreased radiotracer activity in the affected
limb in all 3 phases of bone scan.7
Nonaccidental Trauma (Child Abuse)
Bone scans are helpful when radiographs are inconclusive or to
detect additional fractures in a suspected case of child abuse. It
helps evaluate the extent and severity of trauma. The type of
trauma is related to patient's size; for example, a small child is
often grasped by the thorax during shaking activity of abuse
producing rib injuries, and usually heavier children are grabbed
by the extremities causing periosteal injuries demonstrated as foci
of abnormal tracer activity often in the diaphysis of appendicular
skeleton. Radiographs of many of these injuries appear normal.
The specific mechanism by which trauma was caused could be
11
better characterized by a bone scan.17 Though bone scan is more
sensitive for rib and undisplaced fractures, it is less sensitive for
skull and symmetric metaphyseal fractures.7 Skeletal survey and
bone scintigraphy should be done in suspected cases of child abuse
as they complement each other in assessing extent and severity of
nonaccidental trauma.18 Sometimes, unexpected incidental vis-
ceral and soft tissue injuries are detected on bone scan done for
this indication.
Conclusion
Bone scan is highly sensitive for early detection of pathologic
bone metabolism, whereas radiographs which detect the morpho-
logical changes are less sensitive especially for early disease detec-
tion. MRI features comparable sensitivity to bone scan in most
scenarios and offers no radiation, the downsides of MRI being cost
and availability. Significant osseous disease can be ruled out with
high certainty if bone scintigraphy is negative. Knowing the clinical
presentation of the patient is very crucial in interpreting bone scans,
as they are very nonspecific. Specificity of bone scan can be
improved using other correlative morphological imaging modalities.
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