Case Author(s): Scott Winner, M.D. and Jerold Wallis, M.D. , 3-21-97 . Rating: #D2, #Q5

Diagnosis: osteomtelitis of the proximal phalynx of the right second toe.

Brief history:

69-year old woman with pain in right second toe.


Plantar flow image of feet

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View second image(bs). Immediate static images

View third image(bs). Two hour delay static images

View fourth image(xr). Radiograph of right foot

Full history/Diagnosis is available below

Diagnosis: osteomtelitis of the proximal phalynx of the right second toe.

Full history:

69-year old woman who removed a corn from her right second toe in November, 1996. She presents with chronic purulent drainage.


21.0 mCi Tc-99m MDP i.v.


There is moderately to markedly increased radiopharmaceutical activity noted on the angiographic, blood pool, and delayed static images in the distal aspect of the proximal second phalanx of the right foot. This is most consistent with osteomyelitis.


Three-phase imaging is a technique used to help differentiate cellulitis from osteomyelitis. The distinction is clinically important because of the therapeutic implications of prolonged treatment when osteomyelitis is diagnosed. Cellulitis demonstrates hyperemia with increased activity diffusely on the blood pool images and subsequent clearance of tracer on the delayed images without focally increased uptake in bone. Typically, osteomyelitis shows increased blood flow with focally or diffusely increased uptake of tracer on the blood pool images. Osteomyelitis differs from cellulitis on the delayed images in that progressive focal accumulation of tracer is seen within the involved bone when osteomyelitis is present. This case demonstrates findings classic for osteomyelitis. A correlative radiograph of the right foot was obtained after bone scintigraphy was performed. This radiograph demonstrated bony destruction in the medial aspect of the second proximal phalanx corresponding in location to the abnormal accumulation of tracer seen on the blood pool and delayed images.

Differential Diagnosis List

Increased uptake on all three phases of the bone scintigraphy can be seen in other disorders, including neuropathic joint disease, gout, fracture, severe arthritis, healing osteonecrosis, and bone tumors. Therefore, it is imperative that correlation with clinical data and other imaging studies be performed in conjunction with the three-phase bone scintigraphy.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Inflammation,Infection)

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Case number: bs073

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