The basics help

When I was a boy, learning nuclear medicine in the good old days, I was schooled in the ‘basics’.

One of the basics was that to diagnose osteomyelitis on a bone scan with any specificity you had to have a typical appearance, which was: focal arterial blood flow on the dynamic phase of the study, focal blood pool, and intense focal uptake on the delayed images.

Oh, and be very cautious about diagnosing osteomyelis in a non-diabetic.

Case in point: a 78 year old man with a red distal phalange of the right 2nd toe and a small ulcer on the tip (present for 4 weeks). Not diabetic.


ocon flow

The blood flow and pool images don’t demonstrate focal intense uptake. it’s a little increased but not enough to say that there is an acute inflammatory condition in the distal phalange.


ocon delayed

It’s ‘warm’ but not as ‘hot’ as the uptake in 1st MTP. Also it’s not right at the tip.

As always SPECT is required.

ocon spect

It’s in the joint. It’s arthritis (with slight subluxation). That’s why the toe was a little red.

Sure the basics help, but SPECT helps more.

Posted in Bone scan, Foot and ankle

More of the same, only different

The last post was an area of segmental osteonecrosis in the right hip.

Here’s another, only slightly different.

This is an 87-year-old woman with 2 weeks history of right hip pain of spontaneous onset.

med pool

There is mild diffuse blood pool uptake in the right hip.

med wb

Focal uptake in the right hip. Mild non-specific uptake around the right knee replacement. No pelvic fractures. No lumbar spine pathology.

med Spect

Focal subchondral uptake in the right superior femoral head, typical of osteonecrosis. Uptake in the hip joint is normal.

Just like the last blog post, only different; no central ‘cold’ area.

Okay, now as a special treat another case.

This is an 88-year-old woman with a knee replacement 2 years ago and a 3 month history of right anterior knee pain.

osborn planar

Linear uptake in the right patella(red arrow). We’ll get to the left knee later.

osborn Spect R

Linear uptake in the body of the right patella. I suspect it’s either a non-displaced fracture or a focus of osteonecrosis (no problem with the femoral or tibial components)…….but that’s not all.

When I was speaking to the woman she was adamant her left knee was worse. She had lateral knee pain for a month. As she saw the doctor who did her right knee replacemt he was more interested in that, probably assuming the problem with the left knee was osteoarthritis.

osborn Spect l

But in the left knee there is avid focal subchondral uptake in the posterior lateral tibial plateau, again typical of osteonecrosis.

So why a bone scan and not an MRI?

Several reasons including the fact that MRI tends to be only one region. In the first case they wanted to look at the hip, pelvis, spine and knee. in the second MRI is seriously degraded by the knee replacement.

Also there is about a 1 -2 week wait for an MRI in our region.



Posted in Bone scan, Hip, Knee, Orthopaedic | Tagged , , ,


A 90 year old woman was referred for a bone scan.

I will be kind. The edited version of this patient’s history….

Pain in the right hip for about 2 weeks. She had an injection in the hip a week ago and the hip got better, but now it’s painful again. Also pain in the back, posterior hip and knee.

Ellem WB

The right hip demonstrates moderate uptake. In a 90 year-old this is most likely arthritis, however, of course, SPECT-CT is needed.


A beautiful example of segmental osteonecrosis of the right femoral head.

Note that there is even a subchrondral ‘cold’ area. Note also that there is no evidence of arthritis of the hip joint.

Nice…..well not for the patient of course.

Posted in Hip, Orthopaedic | Tagged , ,

An easy one

A 74-year-old woman was referred with the following history:

Chronic ulcer over the tip of the right great toe for 3 months.
Diabetic for 10 years.  ? Osteomyelitis.

There was no history of trauma. On examination her toe was swollen and red but painless. There was a small ‘clean’ ulcer at the tip of the big toe.

The scan:

sadi flow

The flow demonstrates increased arterial blood flow and blood pool activity in the right 1st toe distal phalanx.

sadi planar

The delayed image demonstrates avid uptake in the distal phalanx.

These changes are typical of osteomyelitis.

sadi CT

Always do the SPECT-CT.  You don’t get paid to miss a fracture.

Posted in Bone scan, Infection, Orthopaedic

A mystery explained (and England’s to blame)

This is the case of a 38-year-old man who had pain in the right first MTP joint.

The request said: ‘Cellulitis in right 1st MTP region. Good response to antibiotics but relapse. ? osteomyelitis.’

The bone scan:

hider BP

mildly increased flow and pool to the right 1st MTP region but not exciting.

hider delayed.png

Focally increased tracer uptake in the right medial sesamoid which should be a fracture. It’s really not ‘hot’ enough to be osteomyelitis.

hider spect

A typical fracture. But why did it respond to antibiotics.

Time for close questioning.

Now, the first question I ask in these situations is, ‘When did you first notice pain in the foot?’

Answer: ‘On the plane’

So, to make the story short, the patient was back from that notorious hellhole, England. Yes, he had done lots of walking and traveled about for 3 weeks. By the time he had returned home he couldn’t put his foot on the ground and his first MTP was swollen and bruised looking.

First, treated for gout. No response.

Second, treated with antibiotics. Good response. Pain decreased, swelling went down but came back after a week. Hence the referral.

So why did a sesamoid fracture respond to antibiotics?

‘What did you do when you were taking the antibiotics?

‘Well the doctor said I had cellulitis and that I should take the week off and keep my foot elevated’. He had a job that kept him on his feet a lot. When he returned to work ‘relapse’

So he had a fracture that responded to rest, not cellulitis that responded to antibiotics.



Posted in Foot and ankle, Orthopaedic

The benefits of multiculturalism

No case today.

One of the problems of a multicultural country such as Australia is that we sometimes have a language barrier with the patients. This is reflected by an incident that happened a few years ago.

I was wandering back into the department after getting lunch when I noticed an old Chinese woman at the front desk who was having quite a time of it. It seems she had come in looking for directions. The problem was that she spoke absolutely no English, but was waving a piece of paper.

The front desk were having none of it. ‘Not here, ‘ they kept repeating, ‘try somewhere else’. Being an humanitarian at heart and, wanting to set an example, I intervened. The woman had one word written on the paper: ‘Liu’.

‘Is this your name? Are you trying to make an appointment?’ I asked with the greatest sympathy (think Mr Darcy – BBC adaption). This was greeted by incomprehension.

More waving of paper.

Now, at that time we had a relief wards-person who was a young, female, ABC (Australian Born Chinese). She just happened to be passing and seeing the problem, immediately offered her help. She was doing a degree at the university and was covering for two weeks as a holiday job. What luck.

‘Can I help?’ she asked me. ‘Great, of course you can. This woman seems lost.’

She turned to the woman, who also looked relieved.

‘WHAT DO YOU WANT ?’ she shouted at her.

‘Wait on,’ I said. ‘Don’t you speak Chinese?’

She turned to me with a look that said ‘Why would you think that?’.

‘No,’ she said quite reasonably. ‘I just thought you needed help’

Now, I’ve been yelling in English at non-English speaking patients for years, even before this young puppy was born. I’ve become quite accomplished at it. I didn’t need her help, thank you.

As it turned out a simple call to bed allocations found two Liu in the hospital. One in maternity just nearby. A simple miming of a pregnant belly and the old woman was on her way, hopefully right direction, with her ‘interpreter’.

Another triumph for multiculturalism.

Posted in Uncategorized

A day in the life*

One of the things’s that people, particularly other doctors, ask me, is: ‘What do you do all day?’.

For someone who has been in nuclear medicine for the last 35 years, and who has been told since he started, that nuclear medicine would not be around in a few years time, it is a victory of sorts that our practices still exist and are still busy.

And yes, we do PET scans. In fact I have two PET reporting days a week. But I’m talking about nuclear medicine. Old school ‘nucs’. Before PET. There is a tendency not only in medicine but in life to get excited by the ‘new thing’ and completely ignore the ‘old thing’.

This blog is strictly ‘old thing’. I have done that as a rearguard action because I don’t want the ‘old thing’ that has kept me happily entertained for 35 years to be ignored or forgotten. I still haven’t mastered it. There are still things that stump or intrigue me every week.

This entry is just a day where we had 14 bone scans. Slightly busier than the usual day in terms of bone scans – we didn’t do cardiac scans on that day because of a camera service – but it will give a partial answer to ‘What do you do all day?’

Case 1:

A 47-year-old man with a 4 year history of low back pain. Seen by a neurosurgeon. The question, as always ‘? facet joint arthritis’. No history of trauma

case 1


case 1 a

Bilateral L5 pars defects. No spondylolisthesis. No acute facet joint arthritis. Nothing else.

Case 2:

A 42-year-old woman with ‘widespread aches and pains’ from a rheumatologist. ‘Widespread aches and pains’ means ‘I think this patient has fibromyalgia but I want to make sure she doesn’t have an inflammatory arthritis, metastases or even widespread osteoarthritis before I send her back to her GP’.

case 2

Whole body blood pool: no inflammatory synovitis

case 2 a

Delayed whole body image: now this is interesting. There seems to be increased uptake at the end of the long bones – the knees, shoulders and ankles. It may be physiological but bone marrow expansion or, less likely, metabolic bone disease look like this.

case 2 b

Increased uptake in the proximal carpal rows bilaterally. This is either osteoarthritis or ‘old’ osteonecosis of the lunates. As she was asymptomatic there we didn’t chase it.

case 2 c

Lumbar spine SPECT. As a general rule, everyone with ‘WAAP’ has low back pain. But most importantly there is no evidence of sacroilitis.

So, no obvious cause for the whole body aches and pain, but the long bone uptake was mentioned along with the possibility of bone marrow expansion (as well as metabolic bone disease and physiologic). Of note, the patient was from the Mediterranean region so thalassemia should be considered.

Case 3:

A  63-year-old woman had a bone scan for skeletal metastases. A PET scan had demonstrated a metastasis in the distal left clavicle

case 3

Nothing much. We do two SPECT-CT to cover the whole spine on most patients, at least for their staging scan. You miss too much if you don’t. in this case there was a small focus in the distal left clavicle and not much else.

Case 4:

An 80-year-old man with low back pain. Gradually improving. A recent X-ray demonstrated a sclerotic lesion in the mid right iliac bone. ? Significance. case 4.png

Something in the region of the right SI joint. Something in the spine and left hip.

case 4 a

Multilevel degenerative disc disease and left L2/L3 facet arthritis.

case 4 b

The ‘something’ in the right SI was a ‘hot’ osteophyte ‘shining through’. I won’t show you every image just quote the conclusion of the report

The sclerotic lesion in the right iliac bone demonstrates no abnormal uptake on the bone scan and is therefore unlikely to be malignant.
Left L2/L3 facet joint arthritis.
Moderate L5/S1 degenerative disc disease with increased tracer uptake in the right side of the disc.
Partial transitional L5 vertebral body as described above.
Osteoarthritis of the superior femoral heads bilaterally.

Not unusual in an 80-year-old, and you may not want to treat any of them, but given that the real question was, ‘does he have a fracture or cancer?’, the answer is ‘no’ and everyone is happy.

Only a bone scan can do this and cover the whole body in one sitting.

Case 5:

A 18-year-old man with a 4 year history of non-specific low back pain. sent from a rheumatologist.

Blood pool:

case 5


case 5 b

Normalish…….mild increased tracer uptake in the SI joints, but that can be normal at 18 years.

case 5 c

Bilateral low grade sacroilitis, in keeping with sero-negative arthritis.

Case 6:

A 63-year-old woman with new diagnosis of breast cancer.

Bilateral L4/5 facet arthritis. No skeletal metastses.

Case 7:

A 23-year-old man with low back pain since a motorcycle accident 6 months previously.


Case 8:

A 24-year-old weight lifter. 10 week history of lower costo-chondral pain on the right.



Case 9:

A 72-year-old woman with right hip and flank pain after a recent fallcase9

No evidence for recent fracture.
Mild right L4/L5 facet joint arthritis.
Minor multilevel degenerative disc disease in the lumbar sacral spine.
Bilateral retro-patella arthritis.

Case 10:

A 48-year-old with back pain not radiating down the legs for 5 years. ? Focal disco-vertebral or facet joint arthritis.case10.png


So the radiating pain may be due a disc prolapse but, as has been said over many years, symptoms and disc prolapse seem to bear no relation to each other.

Our neurosurgeons like to make sure there are no other causes for the symptoms before they consider surgery. Wisely so, in my humble opinion.

Case 11:

A 39-year-old with a new diagnosis of carcinoma of the breast.


Case 12:

This is a 78-year-old man with moderate occipital pain of 6 months duration. No trauma, no precipitants. No history of anything.



case12 a
Avidly increased tracer uptake predominantly involving the dens in the midline which coupled with calcification of the transverse ligament of the atlas is most suggestive of crowned dens syndrome secondary to CPPD disease.

Case 13:

As we are attached to a hospital, the last cases of the day are usually geriatric inpatients who have ‘had a fall’ and are ‘unable to weight bear’. They usually arrive in their bed and it takes all the staff members (including the revered director) to transfer them.

The bone scan is used to see if they can be mobilized. The Xrays in A&E are usually normal (otherwise they would be in the orthopaedic ward) or the injury is not sufficent to explain why they basically can’t move.

Nuc Med to the rescue!

This is a 84-year-old woman whose request form read: ‘Recent fall with right shoulder pain also lower back pain. ? Recent fractures’.


Blood pool is okay. Note the right shoulder. Also note the position on the scanning bed and the size of the patient.


Okay, the back looks a mess. So does the shoulder. At least we can see fractures of the right 2nd and 3rd ribs.


Severe multilevel degenerative disc disease. Previous laminectomy and fusion and finally, a T8 vertebral fracture. Old T11 fracture.


The right shoulder is severe OA not a fracture. The right ‘shoulder pain is the fractures of the 2nd and 3rd ribs.


Recent fractures of the right 2nd and 3rd ribs anteriorly.
Severe osteoarthritis of the right shoulder.
Recent fracture of the T8 vertebral body.
Old fracture of T11.
Multilevel moderately severe degenerative disc disease in the thoracic and lumbar spine.

Case 14:

An 84-year-old man (from the geriatric ward via A&E – normal Xrays): recent fall in the backyard. Mid back pain. Also has pain in the lateral aspect of the right knee.


Increased uptake in L1 the right lateral femoral condyle and both hips.


Fracture superior end-plate of L1 and severe OA of the left hip joint.


Severe OA of the left hip joint.


Recent L1 superior end plate fracture.
Possible fracture (non displaced) of the lateral aspect of the right lateral femoral condyle (arrowed).
Moderately severe osteoarthritis of both hips.
No evidence of a pelvic or hip fracture.

Home time homily:

We also did two thyroid scans and a renal scan for PUJ obstruction. I spoke to each of the patients individually in a language common to us both (English – loudly for those born overseas). All reports finished by 5:00pm.

Not digging ditches but and honest days work.

*tribute to the Beatles. If you listen to the song again you can see how closely my day corresponds to that of the protagonist of the song, except for the bit about smoking a joint and I don’t think an hour’s train trip home reading a Desmond Bagley novel was mentioned in the song either. 


Posted in Uncategorized