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Atlas of Nuclear
Medicine in
Musculoskeletal
System
Case Oriented Approach

Seoung-Oh Yang
So Won Oh
Yun Young Choi
Jin-Sook Ryu
Editors
123
Atlas of Nuclear Medicine
in Musculoskeletal System
Seoung-Oh Yang • So Won Oh
Yun Young Choi • Jin-Sook Ryu
Editors
Atlas of Nuclear
Medicine in
Musculoskeletal System
Case-Oriented Approach
Editors
Seoung-Oh Yang So Won Oh
Department of Nuclear Medicine Department of Nuclear Medicine
Dongnam Institute of Radiological Seoul National University
and Medical Sciences Boramae Medical Center
Busan, Republic of Korea Seoul, Republic of Korea
Yun Young Choi Jin-Sook Ryu

Department of Nuclear Medicine Department of Nuclear Medicine
Hanyang University College of Asan Medical Center, University
Medicine of Ulsan College of Medicine
Seoul, Republic of Korea Seoul, Republic of Korea
ISBN 978-981-19-2676-1 ISBN 978-981-19-2677-8 (eBook)

https://doi.org/10.1007/978-981-19-2677-8
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
To the patients of all cases presented in this atlas textbook
Preface
Many nuclear medicine textbooks and case studies in forms of atlas have
been published so far, but there seems to be no in-depth nuclear medicine
imaging atlas focused on diseases of the musculoskeletal system. Since an
independent volume focusing on nuclear imaging of musculoskeletal disease
has been rare, publication of this book has its significance. In the attempt to
cover a specified area of musculoskeletal nuclear medicine, this book includes
a large number of correlative clinical images in musculoskeletal disorders.
Therefore, the authors wish to write about common cases as well as rare mus-
culoskeletal disorders in which various imaging techniques of nuclear medi-
cine (bone scan, SPECT, SPECT/CT, PET/CT, etc.) are useful based on the
author’s clinical experience in many different hospitals.
Nuclear medicine imaging in the musculoskeletal system with its ability to
assess disease activities has contributed to accurate diagnosis and improved
medical and surgical treatment. This book is intended to share the reading
experiences of the authors with nuclear medicine and radiology residents and
board specialists, and to help other clinicians who manage musculoskeletal
disorders such as orthopedic and rheumatology, through various cases of
musculoskeletal disorders to support their patient care. We aim to publish an
easy-to-read clinical atlas by organizing the proper roles and features of vari-
ous nuclear medicine imaging technics in musculoskeletal disorders by case-
oriented approach.
Please consider that the format of each chapter varies according to the
characteristics of each chapter title, and it is challenging to achieve complete
integrity by respecting the opinions of the authors of each chapter. The editors
wish to thank all contributors who spent much time and efforts in the prepara-
tion of their chapters. All the authors who participated in this issue are experts
in their field. We are indebted to them for their time and effort.
It is our expectation that the original purpose of publishing cases of mus-
culoskeletal disease including various nuclear medicine images experienced
in hospitals in Republic of Korea as a case-oriented textbook has been ful-
filled to a certain extent and becomes a helpful book to readers.
Busan, Republic of Korea Seoung-Oh Yang

Seoul, Republic of Korea So Won Oh
Seoul, Republic of Korea Yun Young Choi
Seoul, Republic of Korea Jin-Sook Ryu
vii
Contents
Part I Inflammatory and Infectious Disorders
1 Musculoskeletal Infections�� 3

Jung Mi Park, Jae Pil Hwang, Joon Ho Choi, Jang Gyu Cha,
and Yu Sung Yoon
2 Septic Arthritis �� 17
You Mie Han
3 Inflammatory Arthritis�� 29
Ju Won Seok
4 Non-inflammatory Arthritis: Osteoarthritis �� 41
Young-Sil An
5 Hypertrophic Osteoarthropathy�� 49
Young Seok Cho
Part II Traumatic and Circulatory Disorders
6
Fracture, Non-union, and Bone Graft�� 63
Soon-Ah Park, Su Jin Lee, Hye Joo Son, and Jung Mi Park
7
Stress Fractures and Sports Injury�� 73
Su Jin Lee
8 Osteonecrosis�� 83
So Won Oh, Jee Won Chai, and Jung Mi Park
9
Complex Regional Pain Syndrome�� 93
Joon-Kee Yoon, Soon-Ah Park, Young Seok Cho,
Jung Mi Park, and Jang Gyu Cha
Part III Spine and Joint Disorders
10 Spine�� 105
Tae Joo Jeon
11 Hip �� 115
Sun Jung Kim and So Won Oh
ix
x Contents
12 Knee Prostheses�� 131

Yoo Sung Song
13 Ankle and Shoulder �� 141
So Won Oh and Jee Won Chai
Part IV Metabolic and Endocrine Osseous Disorders
14 Metabolic Bone Disease �� 157

Jin-Sook Ryu and Hye Won Chung
15 Osteoporosis�� 179
Seoung-Oh Yang, Jung Mi Park, Hye Joo Son, Jang Gyu Cha,
Jee Won Chai, and So Won Oh
16 Fibrous Dysplasia�� 195
Yong-il Kim and Jin-Sook Ryu
Part V Musculoskeletal Neoplastic Disorders
17 Primary
Bone and Soft Tissue Tumors�� 205
Jin Chul Paeng and Seoung-Oh Yang
18 Metastatic Musculoskeletal Tumors �� 217
Young-Sil An and Seoung-Oh Yang
19 Marrow Replacement Disorders�� 227
Joo Hyun O and Ie Ryung Yoo
Part VI Miscellaneous Features in Musculoskeletal

Nuclear Imaging
20 Soft
Tissue Uptake of Bone Scan Agents�� 239
Yun Young Choi and Soo Jin Lee
21 Musculoskeletal
Nuclear Imaging Pitfalls �� 257
Yun Young Choi, Ji Young Kim, and Seoung-Oh Yang
Index�� 269
Contributors
Young-Sil An Department of Nuclear Medicine and Molecular Imaging,

Ajou University School of Medicine, Suwon, Republic of Korea
Jang Gyu Cha Department of Radiology, Soonchunhyang University
Hospital, Bucheon, Republic of Korea
Jee Won Chai Department of Radiology, Seoul National University
Boramae Medical Center, Seoul, Republic of Korea
Young Seok Cho Department of Nuclear Medicine, Samsung Medical
Center, Sungkyunkwan University School of Medicine, Seoul, Republic of
Korea
Joon Ho Choi Department of Nuclear Medicine, Soonchunhyang University
Yun Young Choi Department of Nuclear Medicine, Hanyang University
College of Medicine, Seoul, Republic of Korea
Hye Won Chung Department of Radiology, Asan Medical Center, University
of Ulsan College of Medicine, Seoul, Republic of Korea
You Mie Han Department of Nuclear Medicine, Dongtan Sacred Heart
Hospital, Hwaseong-si, Gyeonggi-do, Republic of Korea
Jae Pil Hwang Department of Nuclear Medicine, Soonchunhyang University
Tae Joo Jeon Department of Nuclear Medicine, Gangnam Severance
Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
Ji Young Kim Department of Nuclear Medicine, Hanyang University
Sun Jung Kim Department of Nuclear Medicine, National Health Insurance
Service Ilsan Hospital, Goyang, Republic of Korea
Yong-il Kim Department of Nuclear Medicine, Asan Medical Center,
University of Ulsan College of Medicine, Seoul, Republic of Korea
Soo Jin Lee Department of Nuclear Medicine, Hanyang University College
of Medicine, Seoul, Republic of Korea
xi
xii Contributors
Su Jin Lee Department of Nuclear Medicine, Ajou University School of

Medicine, Suwon, Republic of Korea
Joo Hyun O Department of Nuclear Medicine, Seoul St. Mary’s Hospital,
The Catholic University of Korea, College of Medicine, Seoul, Republic of
Korea
So Won Oh Department of Nuclear Medicine, Seoul National University
Boramae Medical Center, Seoul, Republic of Korea
Jin Chul Paeng Department of Nuclear Medicine, Seoul National University
Jung Mi Park Department of Nuclear Medicine, Soonchunhyang University
Soon-Ah Park Department of Nuclear Medicine, Wonkwang University
School of Medicine, Iksan, Republic of Korea
Jin-Sook Ryu Department of Nuclear Medicine, Asan Medical Center,
University of Ulsan College of Medicine, Seoul, Republic of Korea
Ju Won Seok Department of Nuclear Medicine, Chung-Ang University,
Hye Joo Son Department of Nuclear Medicine, Dankook University College
of Medicine, Cheonan, Republic of Korea
Yoo Sung Song Department of Nuclear Medicine, Seoul National University
Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
Seoung-Oh Yang Department of Nuclear Medicine, Dongnam Institute of
Radiological and Medical Sciences, Busan, Republic of Korea
Ie Ryung Yoo Department of Nuclear Medicine, Seoul St. Mary’s Hospital,
The Catholic University of Korea, College of Medicine, Seoul, Republic of
Korea
Joon-Kee Yoon Department of Nuclear Medicine, Ajou University Medical
Center, Suwon, Republic of Korea
Yu Sung Yoon Department of Radiology, Soonchunhyang University
Part I
Inflammatory and Infectious Disorders
Musculoskeletal Infections
1
Jung Mi Park , Jae Pil Hwang , Joon Ho Choi ,
Jang Gyu Cha, and Yu Sung Yoon
Abstract Keywords
Pedal ulcer occurs in approximately 25% of the Diabetic foot infection · Chronic prosthetic
diabetics. Three-phase bone scan plays a role in joint infection · Charcot foot · Pyogenic
the assessment of vascular supply including spondylitis
small arteries and capillary vessels in diabetic
foot ulcer. Peri-prosthetic joint infection occurs
in 1%–2% of primary and in 4% of revision 1.1 Diabetic Foot Infection
arthroplasties. Serum CRP may be less specific
after post-operative infection and antibiotics 1.1.1 Clinical Course, Assessment,
therapy; however, combined WBC scan with and Treatment
three-phase bone scan can detect peri-prosthetic
infection accurately. Charcot neuropathic osteo- Development of pedal ulcer can be estimated to
arthropathy is a non-inflammatory and progres- occur in 25% of the diabetics. Diabetic foot dis-
sive destruction of the bone and joint. Bone order is the most common cause of lower extrem-
single-photon emission computed tomography/ ity amputations [1]. Hyperglycemia can cause
computed tomography (SPECT/CT) provides an direct damage to the nerves and blood vessels.
additional anatomical information to distinguish Diabetic vascular disease has three components:
from bone and soft tissue inflammation or infec- arteritis and small vessel thrombosis, neuropathy,
tion in evaluating Charcot foot. Typical pyogenic and large vessel atherosclerosis. Once tissue
spondylitis affects two adjacent vertebrae and damage has occurred in ulcer or gangrene, the
the intervening disc. Differential diagnosis for two main threats are infection and ischemia.
tuberculous spondylitis could be performed with Various foot ulcer classifications have been pro-
clinical symptom and imaging findings. posed to organize the appropriate treatment plan:
the University of Texas diabetic foot ulcer clas-
sification is based on ulcer depth and is graded
J. M. Park (*) · J. P. Hwang · J. H. Choi according to the presence or absence of infection
Department of Nuclear Medicine, Soonchunhyang and ischemia. Many ulcers where critical isch-
University Hospital, Bucheon, Republic of Korea
e-mail: [email protected];
emia exists fail to heal and lead to irreparable tis-
[email protected]; [email protected] sue damage and amputation [2].
J. G. Cha (*) · Y. S. Yoon
The 5-year mortality in patients with diabetes
Department of Radiology, Soonchunhyang University and critical limb ischemia is 30%, and the 5-year
Hospital, Bucheon, Republic of Korea mortality in patients with diabetic foot infections
e-mail: [email protected]; [email protected]
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 3
S.-O. Yang et al. (eds.), Atlas of Nuclear Medicine in Musculoskeletal System,
https://doi.org/10.1007/978-981-19-2677-8_1
4 J. M. Park et al.
who have foot amputations is about 50% [3]. While transluminal angioplasty in the case of bedridden
the neuropathic foot is characterized by warm, dry, patients and patients with life-threatening sepsis
bounding pulses as a result of peripheral vasodila- and extensive muscle necrosis.
tion, callosities, painless penetrating ulcers at pres-
sure points, painless necrosis of toes, spreading Case 1.1
infection along plantar spaces, and loss of pain and A 58-year-old man was referred from an outside
thermal sensation, the ischemic foot is character- hospital; he was treated for necrosis of the left
ized by cold, absent pulses, trophic changes, pain- first toe for 3 months. He had a history of having
ful ulcers around heels and toes, and claudication his entire right toes amputated 3 years ago for
and rest pain. Although these factors may co-exist, atherosclerosis obliterans. His left first to third
it is important to early detect ischemia in the dia- toes were discolored black, and gangrene was
betic foot ulcer. Diabetes itself shows a 25% progressing. Enterobacter cloacae was cultured
increased risk for peripheral arterial disease [4]. from his wound; he was treated with antibiotics.
Bone scan can provide a useful assessment of vas- His angiography showed multifocal stenosis in
cular supply including small arteries and capillary both superficial femoral arteries. His plain radi-
vessels [5]. Proper vascular assessment in small ography could not depict any significant bone
vessel disease with associated gangrenous toes can abnormality on his left toes. However his three-
be help to provide a successful treatment with phase bone scan showed perfusion defect in the
debridement and minor amputation instead of wide left first to third toes with complete absence of
amputation. In chronic and progressive diabetes, a bone uptake (Fig. 1.1). WBC SPECT/CT demon-
conservative surgical approach such as revascular- strated the strong WBC uptake in the left fourth
ization can be considered. But primary amputation and fifth toe soft tissue, as well as a cold defect in
is better than revascularization or percutaneous the left first to third toe gangrene (Fig. 1.2).
a b c
Fig. 1.1 There is no significant abnormal bone lesion in observed on the blood pool image and bone phase image
the left foot plain radiography (a). Perfusion defects and of the three-phase bone scan (b, c)
loss of bone uptake in the left 1st–3rd toes are clearly
a b
Fig. 1.2 WBC scan and SPECT/CT show cold defects in all of the left toes as well as increased uptake in the soft tissue
overlying the 3rd–5th toes (a, b)
1 Musculoskeletal Infections 5
1.2 Chronic Prosthetic Joint (PMMA) beads can become colonized by bacte-
Infection ria due to rapid decrease of local antibiotic con-
centration, resulting in new biofilm formation
1.2.1 Clinical Course, Assessment, [6]. In patients with numerous previous revi-
and Treatment sions, or when local conditions require time,
two-stage exchange with 4- to 6-week antibiot-
Peri-prosthetic joint infection (PJI) occurs in ics treatment can be applied. Longer intervals
1%–2% of primary and in 4% of revision arthro- (>8 weeks) of persistent sign of infection,
plasties. Management of PJI requires multiple debridement, and antibiotic-loaded spacer
surgical revisions and long-term antimicrobial cement are used for dead space management
treatment. About two thirds of PJI results from with two-stage revision surgery for treatment of
intra-operative inoculation of microorganisms golden standard.
[6]. However, all prosthetic joints have hematog-
enous seeding from a distant primary focus, Case 1.2
where highly vascular peri-prosthetic tissue is A 78-year-old woman with diabetes visited the
exposed to the highest risk of hematogenous hospital for discharge from the right pre-tibial
infection in the first years after implantation. The area, which had undergone knee arthroplasty at
most common primary foci are skin and soft tis- an outside hospital 7 months ago. She underwent
sue infection, respiratory tract infections, gastro- prostheis removal due to septic arthritis and anti-
intestinal infections, or urinary tract infections. biotic bead insertion, and baseline three-phase
According to the definition criteria for PJI by the bone scan showed increased perfusion and joint
European Bone and Joint Infection Society uptake in the right knee joint and pre-tibial space
2018 in Helsinki, if there is one more criteria, PJI (arrow) suggesting septic arthritis (Fig. 1.3). Her
including chronic infection can be diagnosed. serum CRP level decreased from 5.2 mg/L to
It shows better sensitivity for diagnosing PJI [7]. 0.13 mg/L after 2 months of antibiotic IV therapy
The sensitivity of synovial fluid culture is and antibiotic bead insertion. She underwent a
45% to 75% with a specificity of 95% [7]. The baseline three-phase bone scan (Fig. 1.3) and 2
sensitivity of intra-operative swab is low, and the months later follow up scan (Fig. 1.4). It was to
swab should be avoided. This is because a swab determine an optimal timing of revision of arthro-
from the wound or sinus tract can mislead by plasty; contrary to expectations, the scan showed
detecting colonizing microorganisms. Generally severely increased perfusion and bone uptake in
three to five intra-operative tissue samples the right tibia shaft (Fig. 1.4). WBC scan also
should be obtained for the culture. Histopathology showed diffuse WBC uptake along the previously
of peri-prosthetic tissue should be considered a inserted antibiotic beads in the tibia (Fig. 1.4).
standard procedure in the diagnosis of PJI. Rapid decrease of local antibiotic concentration
In PJI caused by low-virulence pathogens, in the inserted antibiotic-coated beads resulted in
blood tests such as WBC, ESR, and CRP are new biofilm formation. She underwent surgery to
often normal [8]. CRP can be increased after sur- remove infectious granulation tissues meticu-
gery, due to post-operative inflammation. Serial lously in the bone marrow with massive irrigation
measurements of CRP are more important for and new cement insertion with VPMMA for
accurate interpretation. In acute post-operative removal of dead space in the tibia. A few months
infections (<4 weeks) or acute hematogenous later, she underwent joint replacement sur-
infections, debridement, antibiotics, and implant gery. Three-phase bone scan and WBC scan
retention are the best treatment. Local antibiotics may be useful for accurate diagnosis of infection
can be additionally used during revision surgery. even when serum CRP returns to normal range
Antibiotic-loaded polymethylmethacrylate after antibiotic treatment.
6 J. M. Park et al.
Fig. 1.3 Pretibial soft tissue a b c

hyperperfusion (arrow) and
diffuse hyperperfusion
surrounding the right knee
joint are seen on the
three-phase bone scan (a, b).
Soft tissue swelling and fluid
collection are seen in the
patellofemoral compartment
of the knee on the plain
radiography (c)
a b c d
Fig. 1.4 Prosthetic removal and antibiotic bead insertion tion widely extends to the tibial shaft (b, c). WBC SPECT/
in the right tibia are seen on the plain radiography (a). CT shows strong WBC accumulation in the tibia, consis-
After 2 months, serum CRP has returned to the normal tent with bone marrow infection (d)
range. Followed up three-phase bone scan finds the infec-
1.3 Charcot Foot progress without proper treatment, and may result
in Lisfranc’s joint destruction and callopse of the
1.3.1 Etiology and Clinical longitudinal arch of the foot. The typical end-stage
Significance appearance of a Charcot foot is the rocker bottom
deformity. Calcaneal insufficiency fracture is an
Charcot neuropathic osteoarthropathy is a dis- uncommon, which can be associated with neuroar-
ease spectrum of the bone, joint, and soft tissue thropathy or severe osteoporosis, and may be
and is non-inflammatory and progressive caused by spontaneous condition or repeated
destruction of the bone and joints. Charcot the- microtrauma of the pull of the calcaneal tendon.
ory is not yet clear for its pathogenesis or mecha-
nism; there is consensus that the cause is
multifactorial including polyneuropathy (loss of 1.3.2 Radiographic Imaging
sensation and proprioception), neurotraumatic,
and neurovascular conditions with combined The Charcot foot can be classified using various
osteoarthropathy [9]. systems according to anatomical landmarks and
From a clinical perspective, its early phase is clinical symptoms. The most common one is the
characterized by a hot or warm, red, and swelling Sanders and Frykberg classification; this classifi-
of foot, often without pain due to polyneuropathy, cation identified five zones of disease distribution
and by osteopenia with fractures. The disease will according to the anatomical location. The most
a b
Fig. 1.5 Plain radiography and sagittal image of 3D foot CT show fracture in the calcaneal tuberosity and fluid collec-
tions at the posterior aspect of the calcaneus and tibiotalar joints (a, b)
a b
Fig. 1.6 Three-phase bone scan shows decreased radioactivity in the calcaneal fracture site and diffusely and mildly
increased perfusion and bone uptake in the talocalcaneal joints (a, b)
commonly involved areas are about 45% in zone Bone SPECT/CT provides an additional anatom-
II in about 35% in zone III of cases. ical information to distinguish bone and soft tis-
Conventional radiographs of the Charcot foot sue inflammation or infection. Bone scintigraphy
are traditionally the standard imaging technique with radiolabeled leukocytes is more specific for
to establish the diagnosis, to stage, and to monitor osteomyelitis [11].
the disease. MRI is a well-known imaging modal-
ity to diagnose a suspected early active Charcot Case 1.3
disease. Early signs of a Charcot foot in MRI are An 82-year-old woman presented to the outpa-
bone marrow edema, soft tissue edema, joint effu- tient clinic due to left heel pain developed 2 days
sion, and subchondral microfractures. MRI of ago. She sprained her foot from walking 3 days
late-stage Charcot foot shows joint destruction, ago and had a long time of diabetes history for
cortical fractures, joint dislocations, bone marrow 25 years. Plain radiography and foot 3D CT
edema, superior and lateral dislocation of revealed right calcaneal tuberosity fracture and
Lisfranc’s joint, prominent well-marginated sub- fluid collections at posterior aspect of calcaneal
chondral cysts, bone proliferation, sclerosis, fracture site and anterior aspect of tibiotalar
debris, intraarticular bodies, and dislocation of joints (Fig. 1.5). 99mTc-DPD three-phase bone
talus and navicular bones [10]. scan and bone SPECT/CT also showed diffusely
Three-phase bone scintigraphy is gener- increased perfusion and bone uptake along the
ally used to exclude osteomyelitis in diabetic anterior and posterior talocalcaneal joints
patients. Increased perfusion and bone uptake (Figs. 1.6 and 1.7). These additionally showed
are not specific to diagnose osteomyelitis, decreased perfusion and bone uptake from bony
because they may also occur in chronic soft tis- fragmentation at calcaneal avulsion fracture site.
sue infections, fractures, and neuropathic joints. Based on the clinical exam including a long his-
8 J. M. Park et al.
a b c
d e f
Fig. 1.7 Bone SPECT/CT shows diffuse osteopenia and head in b) on its fusion axial, sagittal, and coronal images
small bony fragment in the talocalcaneal joint area as well (a–c), axial, sagittal, and coronal CT images (d–f)
as the avulsion fracture in the calcaneal tuberosity (arrow-
tory of diabetes mellitus, no evidence of tender- decreasing friction between skeletal and soft tissue
ness, and imaging work-ups including avulsion structures, including bone-tendon, bone-skin, and
fracture and joint activity of common location, tendon-ligament interfaces. The bursa can be
early Charcot arthropathy was suggested. divided into anatomical and adventitious bursae;
lateral malleolar bursa is adventitious type. Lateral
malleolar bursitis is a rare cause of ankle pain and
1.4 Malleolar Bursitis swelling characterized by bursa wall thickening
and excess bursal fluid accumulation. This disease
1.4.1 Etiology and Clinical is caused by the inflammation or infection, repeti-
Significance tive irritation, constant pressure, swelling, compli-
cation from arthritis, and repeated stress or injury
The bursa is fluid-containing, extra-articular of the lateral malleolar area of the ankle. Treatment
closed sacs that provide cushioning and assist in includes a lifestyle modification, combination of
oral or parenteral antibiotics, and needle aspiration lateral malleolar area on blood pool phase image
or incisional drainage, and surgical intervention and mildly increased uptake in the distal fibular
may be necessary in some cases. area suggesting reactive change on delay bone
phase image (Fig. 1.10). Blood pool phase
SPECT/CT showed localized increased uptake
1.4.2 Radiographic Imaging with diffuse soft tissue swelling centering
around the lateral malleolar bursa of right ankle.
Typical ultrasonographic finding is a fluid- Otherwise, delay bone phase SPECT/CT
filled anechoic structure with a thickened showed increased bone uptake suggesting reac-
hyperechoic wall. On MRI, the bursa is seen as tive change in the right distal fibula (Fig. 1.11).
a high T2 fluid-filled structure, and CT shows
the inflamed bursa as hypodense with an
enhancing wall [12]. Three-phase bone
scan and perfusion SPECT/CT show hyper-
emia and focal increased bone uptake. In addi-
tion, SPECT/CT can provide higher diagnostic
accuracy and anatomical information distin-
guished bone and soft tissue inflammation or
infection due to additional CT imaging tech-
nique [11].
Case 1.4
A 52-year-old man presented to the outpatient
clinic due to right ankle pain with ulceration
(Fig. 1.8). He has had diabetes mellitus for a
long time. Radiographs showed no bony abnor-
mality except for soft tissue shadow correspond-
Fig. 1.9 Plain radiography of both feet and ankles
ing the lesion in the right lateral malleolar area
(Fig. 1.9). 99mTc-DPD three-phase bone scan
showed increased soft tissue uptake in the right
a b
Fig. 1.10 Three-phase bone scan shows increased perfu-

Fig. 1.8 Photograph of lateral malleolar lesion of right sion in the swelling area of the right lateral malleolus and
ankle at the time of admission mildly increased bone uptake in the lateral malleolus (a, b)
10 J. M. Park et al.
a b c
d e f
Fig. 1.11 Blood pool and bone SPECT/CT; blood pool anatomical differentiation between soft tissue and bone,
phase axial, bone phase axial, bone axial CT images (a– while in a planar three-phase bone scan increased uptake
c), blood pool phase coronal, bone phase coronal, and area can be obscure for an exact localization
bone coronal CT (d–f). SPECT/CT can provide accurate
1.5 Pyogenic Spondylitis bral osteomyelitis, septic discitis, and epidural

abscess. Pyogenic spondylitis usually develops
1.5.1 Etiology and Clinical from bacterial origin. The arterial route is more
Significance widespread than the venous route, usually from the
skin, oral cavity, respiratory tract, and genitouri-
The term “pyogenic spondylitis” is a broad term nary tract [13]. The vertebral segmental artery pro-
which includes pyogenic spondylodiscitis, verte- vides an intervening disc as well as the upper and
lower portion of vertebrae. Thus, typical pyogenic The most characteristic features of tubercu-
spondylitis affects two adjacent vertebrae and the losis spondylitis are (a) predominantly pattern
intervening disc. The spines infections could of bone destruction, (b) relatively preserved disc
involve all levels of the spines. The result shows the due to a lack of proteolytic enzymes in myco-
lumbar spine (45–50%) is the most common site, bacteria [17], (c) enhanced focal and heteroge-
and the rest of the level is the thoracic (35%), cervi- neous contrast of vertebral bodies, (d)
cal (3–20%), and sacral regions [14]. well-defined perivertebral regions of abnormal
signal intensity, and (e) rim enhancement of ver-
tebral intraosseous lesion in the sagittal plane.
1.5.2 Radiographic Imaging On the other hand, the common findings of pyo-
genic spondylitis are (a) mainly the appearance
Radionuclide studies showed more sensitive of intervertebral disc disease, (b) mild to moder-
results than radiograph images in early stages. ately peridiscal bone involvement, (c) relatively
Bone scans reveal little anatomical details and diffuse and homogeneous enhancement of the
can be positive in osteoporotic fractures and neo- vertebral body, (d) ill-defined abnormal signal
plastic disease. Magnetic resonance imaging intensity paraspinal region, and (e) interverte-
(MRI) is known as the gold standard for detect- bral rim enhancement findings. If three or more
ing pyogenic spondylitis. The infection com- of the five criteria are found, it is strongly sug-
monly begins at the anterolateral vertebral body gestive of tuberculosis or pyogenic spondylitis
near the endplate [15]. Associated edema is [17].
declared and includes much of the vertebral body
and intervertebral disc. MRI is also a dependable Case 1.5
method for evaluating and assessing the spinal An 87-year-old woman visited an outpatient
canal, especially the epidural space and spinal clinic with her back pain for 4 months, and ten-
cord. Epidural abscess with neurological deficit derness was elicited at left lower back area. The
is a surgical emergency [13]. laboratory findings showed elevated ESR and
CRP. MR showed enhancement of bone marrow
and disc in L4–L5 with bilateral paravertebral
1.5.3 Differential Diagnosis abscess and phlegmon (Fig. 1.12a). Three-phase
with Pyogenic Spondylitis bone scan with bone SPECT/CT showed diffuse
Versus Tuberculous increased perfusion and bone uptake in the L4
Spondylitis and L5 vertebare (Fig. 1.12c–f). Pyogenic spon-
dylitis was diagnosed by bone biopsy.
Infective spondylitis may result from hematoge-
nous spread, direct external inoculation, or con- Case 1.6
tiguous tissues. The hematogenous arterial route A 64-year-old man visited an outpatient clinic for
is predominant in pyogenic spondylitis, starting back pain and left leg numbness sensation with
infection from various sites to the vertebral col- fever. Laboratory results showed positive for the
umn. Contrary to pyogenic infections, tubercu- blood TB-specific antigen. MR revealed well-
lous infection usually spread from the venous defined paravertebral soft tissue abscess forma-
system such as Batson’s venous plexus. In the tion (Fig. 1.13), combined with edematous bone
case of tuberculous spondylitis, there are few change and heterogenous cortical loss but rela-
clinical symptoms such as fever, pain, and swell- tively preserved disc. Three- phase bone scan
ing due to infection, and the disease progresses and following SPECT/CT showed increased per-
gradually. However, infective spondylitis is fusion and bone uptake in the L3–L4 bodies with
highly likely to be accompanied by severe pain increased perfusion in the paravertebral soft tis-
and high fever [16]. sues at the L3–L5 level (Fig. 1.13c).
a b
c d
L-spines
e f
Fig. 1.12 Contrast-enhanced MR images of L-spines vening disc (arrows in b). Three-phase bone scan (c, d)
show enhancement of the bilateral paravertebral abscesses and bone SPECT/CT (e, f) show increased perfusion and
(arrows in a) and two adjacent vertebrae with the inter- bone uptake in the L4 and L5 spines
Fig. 1.13 Contrast-

enhanced MR images of a b
L-spines show multiple
paravertebral abscesses
(arrowheads in a, b) and
bone loss in the L3
(arrow in b). Posterior
view of three phase bone
scan shows subtle
increased soft tissue
perfusion in the left
paravertebral area
(arrowhead in c), mildly
increased perfusion in
the L3 and L4 (arrows in
c), and relatively subtle
increased bone uptake in c d
the L3 and L4 (c, d).
Bone SPECT/CT shows
bone defect with mildly
increased bone uptake in
the L4 body (e, f)
e f
Case 1.7 in the left side of screw of L3 body (Fig. 1.14c,

A 58-year-old man visited an outpatient clinic d). White blood cell scan with SPECT/CT dem-
due to back pain after receiving interbody fusion onstrated cold defect in L2 and L3 spines
4 months ago. He was treated with antibiotics (Fig. 1.14e, f) suggesting osteomyelitis. In
intensively, however his clinical symtpoms were chronic sponydlitis, the presence of necrotic
not improved. MR showed hyperenhancement bones can reduce the effectiveness of antibiotic
on L2 and L3 bodies and paravertebral soft tissue treatment by preventing the antibiotics
(Fig. 1.14a, b). Prosthetic loosening and associ- from entering the tissue, which in turn may pro-
ated edema were also revealed. Three-phase bone duce a new inflammation or thrombosis and
scan showed increased perfusion and bone uptake result in more severe necrosis.
a b c
d e f
Fig. 1.14 Contrast-enhanced MR images of L-spines (c, d). WBC scan and SPECT/CT show cold defects in the
show enhancement of paravertebral soft tissue at the level L2 and L3 bodies in comparison to the uptake in other
of L2–L3 (a, b). Bone scan and SPECT/CT show lumbar spines suggesting osteomyelitis (e, f)
increased perfusion and bone uptake in the level of L2-L3
Case 1.8
A 78-year-old man presented to the outpatient Teaching Points
clinic with neck pain and fever. Laboratory study • Bone scan can provide a useful assess-
showed elevation of ESR and CRP. MR demon- ment of vascular supply including small
strated decreased intervertebral space and paraver- arteries and capillary vessels in diabetic
tebral abscess at C6–C7 level with anterior foot.
epidural abscess formation (Fig. 1.15a). Three- • Even CRP can be less specific after
phase bone scan revealed mildly increased perfu- post-operative infection and antibiotics
sion and bone uptake in the lower C spines at therapy, combining WBC scan with
anterior and oblique views (Fig. 1.15c–e). three-phase bone scan can be useful for
Empirical antibiotic treatment was applied for detecting peri-prosthetic infection
pyogenic spondylitis. Bone scan for cervical spon- accurately.
dylitis should be carefully reviewed, because it has • Early detection and proper treatment of
a relatively low incidence and bone uptake of C Charcot foot are important for preven-
spine lesion is easily obscured in comparison tion of disease progression and predic-
to the thoraco-lumbar spines. tion of disease prognosis.
a b
c d e
Fig. 1.15 Contrast-enhanced MR images of C-spines increased perfusion in the lower C spine area and increased
show paravertebral abscess at the level of C4–C7 (arrow, bone uptake in the lower C spines on the three-phase bone
double arrows in a, b) and anterior epidural abscess at the scan (arrowheads in c–e)
C6–C7 level (arrowheads in a). Suspicious mildly
• SPECT/CT allows accurate anatomical involvement of bony inflammation or

correlation with CT to functional infor- infection.
mation with SPECT; it can improve the • Pyogenic spondylitis involves various
diagnostic accuracy for inflammation or clinical entities such as pyogenic spon-
infection, traumatic injury, and degen- dylodiscitis, septic discitis, vertebral
erative change of the foot and ankle. osteomyelitis, and epidural abscess.
• WBC SPECT/CT can help increase • Pyogenic spondylitis affects two adja-
diagnostic accuracy for infections in vio- cent vertebrae and intervening disc and
lated bone lesions compared to relatively infectious spondylitis can show cold
low sensitivity of three-phase bone scan. defect in WBC scan.
• Malleolar bursitis is a rare inflammatory • Differential diagnosis between pyo-
disease involving the soft tissue of the genic spondylitis and tuberculous spon-
ankle and foot. dylitis can be made by clinical symptom
• Blood pool and delay bone phase and imaging findings.
SPECT/CT can help discriminate the
References infections, particularly chronic and low-grade infec-

tions. Int Orthop. 2017;41:1315–9.
9. Jones E, Manaster B, May D, Disler D. Neuropathic
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Joseph WS, Karchmer AW, LeFrock JL, Lew DP,
10. Rosskipf A, Loupatatzis C, Pfirrmann C, Boni T,

Mader JT, Norden C, Tan JS. Diagnosis and treat-
Berli M. The Charcot foot: a pictorial review. Insight
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11. Yoo IR. Bone SPECT/CT of the foot and ankle:

3. Lipsky BA, Berendt AR, Cornia PB, Pile JC,
potential clinical application for chronic foot pain.
Peters EJ, Armstrong DG, Deery HG, Embil JM,
Nucl Med Mol Imaging. 2020;54:1–8.
Joseph WS, Karchmer AW, Pinzur MS, Senneville
12. Hirji Z, Hunjun J, Choudur H. Imaging of the

E. Infectious diseases society of America. Clinical
Bursae. J Clin Imaging Sci. 2011; https://doi.
practice guidelines for the diagnosis and treat-
org/10.4103/2156-7514.80374.
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Orthop. 2012;36(2):397–404.
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14. Jaramillo-de la Torre JJ, Bohinski RJ, Kuntz

analysis: glycosylated hemoglobin and cardiovas-
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5. Masaoka S. Evaluation of arterial obstructive leg and
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medical treatment of spine infections. Clin Orthop
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Septic Arthritis
2
You Mie Han
Abstract Keywords
Septic arthritis is a painful infection in a joint Septic · Infectious · Arthritis · Tuberculous

induced by an infectious agent. Release of Bone · Scintigraphy
proteolytic enzyme from bacteria and inflam-
matory cells may cause articular cartilage
damage within hours. So, prompt diagnosis 2.1 Etiology
and treatment are essential to prevent signifi- and Pathophysiology
cant morbidity and mortality. Although arthro-
centesis is commonly used to make an accurate Septic arthritis is also known as infectious arthri-
diagnosis of septic arthritis, imaging modali- tis or pyogenic arthritis, a painful infection in a
ties are helpful to evaluate the disease. Whole- joint induced by an infectious agent. It can be
body or three-phase bone scintigraphy has caused by bacterial, viral, mycobacteria, or fun-
been widely used in diagnosis of septic arthri- gal infections. The most common causative
tis. Although its findings are nonspecific, it is organism is S. aureus (Staphylococcus aureus).
a sensitive study to diagnose septic arthritis An organism can enter the joint by the blood
and detect associated bone erosion or osteo- stream from another infected body focus, by con-
myelitis under suspicion of infectious condi- tiguous spread from infected periarticular tissue,
tion. A total of six cases of septic arthritis are or by direct inoculation via penetrating injury,
presented in this chapter: four bacteria- surgery, or injection. Knees and hips are com-
confirmed and one bacteria-suspected infec- monly affected joints, but septic arthritis can
tions and one tuberculous infection. Each case affect other joints including both large and small
contains a closely correlated combination of joints. Symptoms and signs of septic arthritis are
images of three-phase bone scintigraphy, sim- acute pain, swelling, redness, and heating sensa-
ple radiography, MRI, and/or PET/CT. tion on the affected joint with discomfort and
limited range of motion. Active bacterial prolif-
eration resulted from invasion of the highly vas-
cular synovium. Release of proteolytic enzyme
from bacteria and inflammatory cells may cause
Y. M. Han (*) articular cartilage damage within hours.
Department of Nuclear Medicine, Dongtan Sacred
Heart Hospital,
Furthermore, increased intra-articular pressure
Hwaseong-si, Gyeonggi-do, Republic of Korea from accumulation of the purulent fluid results in
e-mail: [email protected]
18 Y. M. Han
necrosis of the synovium, cartilage, and bone. Septic arthritis is potentially serious, because it
Revascularization, synovial proliferation, granu- can cause rapid joint destruction leading to per-
lation tissue, and finally bony ankylosis can also manent deformities and irreversible loss of joint
develop according to progression of arthritis. function in 25–50% [1].
a b c
Bone
Joint
capsule
Synovial
membrane
Cartilage
Synovial
cavity
containing
synovial fluid
Septic arthritis – pathophysiology Normal (a). In the acute stage (b), there is an acute synovial inflammation
with a purulent joint effusion. Soon articular cartilage is damaged by proteolytic enzyme secreted from bacteria
and cells. If the infection is not controlled, the cartilage may be completely destroyed and subcortical bone is
eroded. Healing may occur with irregular joint space narrowing and bony ankylosis (c)
2.2 Diagnosis Scintigraphy with 99mTc-labeled phosphonates

is helpful for a supportive study in the septic
Diagnosis of septic arthritis is generally based on arthritis and is sensitive, though not specific, to
the patient’s history, clinical examination, and lab- detect destructive bone change or associated
oratory and imaging findings. Imaging modalities osteomyelitis which shows increased bone turn-
such as radiography, CT (computed tomography), over. In three-phase bone scintigraphy, because
MRI (magnetic resonance image), ultrasound, or of hyperemia in synovial vessels to the affected
bone scintigraphy can help determine areas of joint, all three phases (flow, blood pool, delayed)
inflammation but cannot confirm the infection. show increased radionuclide uptake [2, 3]. Flow
Arthrocentesis is used to make an accurate diagno- and blood pool images show diffusely increased
sis of septic arthritis. However, false-negative activity at the suspected periarticular area.
gram stains and cultures of synovial fluid can Delayed bone images obtained at 2–4 h after
occur. The infection can damage rapidly and injection of radiopharmaceuticals may demon-
severely the cartilage and bone within the joints, strate diffuse mild bone marrow uptake in the
so urgent treatment is needed. Prompt diagnosis is articular confinement and continued intense bone
essential for the better outcome, and MRI is the uptake with process of destructive cortical bone
initial imaging study of choice for the septic arthri- change. Periarticular bone marrow uptakes also
tis. Septic arthritis should be differentiated from possibly represent so-called reactive bone mar-
acute osteomyelitis because the treatment strate- row edema on MRI [4, 5]. In addition, other fac-
gies are not identical. Sometimes, septic arthritis tors (e.g., trauma, osteoarthritis) could also cause
and acute osteomyelitis can co-exist. a false-positive scan.
2 Septic Arthritis 19
F-FDG PET (fluorine-18 fluorodeoxyglucose

18
thick synovial membrane and grafted tissue (*),
positron emission tomography)/CT has an incre- a large joint effusion, and mildly enhanced bone
mental value in detection of infectious disease due marrow in the periarticular bones. 99mTc-HDP
to its excellent sensitivity and specificity. In pyo- (hydroxymethylene diphosphonate) three-phase
genic arthritis, FDG uptake is increased at synovium bone scintigraphy was performed on the third
which has abundant neutrophils. However, day after the MRI. Images of flow and blood
increased FDG uptake is a usual feature in various pool phases showed diffusely increased soft tis-
types of arthritis, because of the increased cellular- sue uptake about right knee joint, suggesting
ity of the synovial membrane in synovitis and syno- synovial hyperemia and inflammation. Delayed
vial hypertrophy. Therefore, it is difficult to bone phase image showed asymmetric diffuse
distinguish the septic arthritis from other types of and mildly increased periarticular bone uptake at
arthritis with PET/CT images only. The advantages the right knee probably due to regional hyper-
of PET/CT are high spatial resolution and the abil- emia (Fig. 2.1).
ity of detecting tissue metabolic state, which reflect
well the extent and severity of the disease [6]. Case 2.2
A 56-year-old woman presented with continuous
pain in the right shoulder. She had a history of
2.3 Tuberculous Arthritis surgical drainage of pus (S. aureus) and antibiotic
therapy for the right shoulder joint and muscle
Tuberculous arthritis is a slowly progressive, infection, which had been developed after injec-
chronic monoarticular infection and is almost tions at a local clinic, 2 months ago.
always combined with tuberculous osteomyelitis. Three-phase bone scintigraphy showed no sig-
Joint invasion may be a result from hematoge- nificantly increased blood flow activity at the right
nous synovial infection or, more commonly, from shoulder. Asymmetric, uneven hot uptake was
epiphyseal or metaphyseal bone infection that noted at the right shoulder on blood pool image.
erodes into the joint space. Hip is the second There was diffuse mild periarticular increased bone
most common site followed by vertebra; it uptake with two focal areas of intense hot uptake at
accounts for about 15% of all cases of musculo- the right humerus head on delayed bone image.
skeletal tuberculosis [7]. As synovial inflamma- There were intra-articular erosive bone changes at
tion is started, granulomatous tissue develops and the right humeral head. Plain radiography showed
expands over the bone at the synovial reflections, focal radiolucencies at the anatomical neck of the
with subsequent cartilage destruction and bone right humerus. These areas were corresponding to
erosions. However, joint destruction occurs in the the areas with focal hot uptake on the delayed bone
late phases of disease, because the lack of proteo- image of three- phase bone scintigraphy.
lytic enzymes in tuberculosis preserves the carti- Postcontrast FS T1W coronal MRI showed focal
lage for a considerable length of time [8, 9]. cortical defects at the same areas of the humerus as
shown on plain radiography and bone scintigraphy.
Case 2.1 There was thick synovial enhancement with small
A 46-year-old man was admitted to the hospital joint effusion, enhancement of surrounding mus-
under suspicion of acute osteomyelitis. He com- cles and tendons, and reactive bone marrow edema
plained of pain and swelling of the right knee in the humerus head. During arthroscopic surgery,
with heating sensation that had been developed pus from the scapular area and synovial prolifera-
on the same day after a slip down. He had a his- tion were noted. Pathologic report was chronic
tory of debridement and skin grafting over the active inflammation, revealing chronic infectious
right knee due to the burn injury 5 months ago. arthritis (Figs. 2.2 and 2.3).
Purulent discharge (S. aureus) was coming from
a small external wound on the right knee. Case 2.3
Postcontrast FS (fat-saturated) T1-weighted A 47-year-old woman was hospitalized under the
(W) sagittal and axial MRI showed enhanced impression of septic arthritis of the right hip. She
20 Y. M. Han
Fig. 2.1 (a, b)

Postcontrast FS T1W a b
MRI: synovial
inflammation and
reactive bone marrow
edema in the
periarticular bones,
grafted tissue (asterisk).
Three-phase bone
scintigraphy 3 days
later: (c, d) periarticular
hot uptake at right knee
on flow and blood pool
phases, associated with
septic arthritis. (e)
Asymmetric diffuse
mild periarticular
increased bone uptake at
right knee, suggestive of c
periarticular bone edema
complained right hip pain, which had developed No microorganisms were found in the bacterial
2 months ago and aggravated recently, extending culture.
to inguinal and buttock areas. The result of aspi- Precontrast T1W and postcontrast FS T1W
ration biopsy was chronic active inflammation. axial MRI showed right hip joint inflammation
a b
8 sec
32 sec
56 sec
Fig. 2.2 Three-phase bone scintigraphy: (a) no signifi- blood pool image. (c) Diffuse mild periarticular increased
cant hyperemia at the right shoulder on flow image. (b) bone uptake with two focal areas of intense hot uptake at
Asymmetric uneven hot uptake at the right shoulder on the right humerus head on delayed image
with enhanced thick synovial membrane and erosions and sclerosis in the femoral head and the
enhanced periarticular soft tissue. Heterogeneous acetabulum (Fig. 2.4).
T1 low signal intensities and contrast enhance-
ments were in the right femoral head and neck Case 2.4
and in the acetabulum. Non-enhanced T1 low A 67-year-old woman was admitted due to spon-
signal intensity area was at the posterior aspect of taneous painful swelling in the left wrist for
the right femoral head, suggesting osteonecrosis. 2 weeks. There was purulent discharge
99m
Tc-HDP three-phase bone scintigraphy (Streptococcus agalactiae) from the left wrist.
showed asymmetric hot uptake at the right hip on Plain radiography of the left wrist showed
flow and blood pool images. Delayed image soft tissue swelling, uneven joint space narrow-
showed asymmetric increased bone uptake in the ing, and periarticular bone erosion and sclero-
right hip joint. There was no significant bony sis. FS T2W coronal MRI showed high signal
lesion on the initial plain radiography. Plain radi- intensity of synovial and parasynovial inflam-
ography taken 7 months later showed uneven nar- mation in the left wrist joint with uneven joint
rowing of the right hip joint space with bone space narrowing, subchondral bone erosions,
22 Y. M. Han
Fig. 2.3 (a) Plain

radiography: focal bone a
erosions (arrows) at the
anatomical neck of the
right humerus. (b) Bone
scintigraphy: focal hot
uptakes at right humerus
head corresponding to
bone erosions. (c)
Postcontrast FS T1W
MRI: bone erosions with
reactive bone marrow
edema in the humerus
head and synovial and
adjacent soft tissue
inflammation
b c
and patchy bone marrow edema. Mid-carpal Case 2.5

joint space was relatively preserved. 99mTc- A 64-year-old man was admitted to the hospital
HDP three-phase bone scintigraphy showed due to incidentally detected gastric cancer during
diffuse hot uptake throughout the left wrist on health screening. He complained pain and swell-
both perfusion and blood pool images, indicat- ing on both knees. He had a clinical history of
ing articular hyperemia and inflammation. intra-articular injection at a local clinic 5 days
Delayed scan shows diffuse periarticular ago. He underwent arthroscopic pus (S. aureus)
increased bone uptake with intense radiotracer drainage and irrigation.
uptakes at proximal and distal carpal (espe- Initial plain radiography of the right knee shows
cially second to fourth carpometacarpal) joint distension of suprapatellar bursa without evidence
areas (Fig. 2.5). of bone lesion. 18F-FDG PET/CT was taken 1 day
a f g
c d
24 sec
48 sec
Fig. 2.4 (a) Precontrast T1W and (b) postcontrast FS uptake in right femoral head and neck and in acetabulum.
T1W MRI: right hip joint and adjacent soft tissue inflam- (f) Initial plain radiography: no significant bone lesion. (g)
mation with bone marrow change in femoral head and Plain radiography taken 7 months later: uneven joint
neck and in acetabulum. Three-phase bone scintigraphy: space narrowing with bone erosions and sclerosis in fem-
(c) asymmetric mild hyperemia, (d) hot uptake at right hip oral head and acetabulum
on blood pool image, (e) periarticular increased bone
after surgical pus drainage and irrigation. Maximum PET/CT images showed intense FDG uptake in the
intensity projection (MIP) image shows intense right knee joint along the synovial lining without
FDG uptake at the right knee. Coronal and sagittal evidence of bone involvement (Fig. 2.6).
24 Y. M. Han
a b
c d
Fr:1-2
Ant Post
e
Fr:11-12
Fr:21-22
Fig. 2.5 (a) Plain radiography: soft tissue swelling, patchy bone marrow edema. Three-phase bone scintigra-
uneven joint space narrowing, and periarticular bone ero- phy: (c, d) diffuse hot uptake throughout left wrist on both
sion and sclerosis. (b) FS T2W MRI: high signal intensity perfusion and blood pool images and (e) periarticular hot
of synovial and parasynovial inflammation with uneven uptakes at carpal bones on delayed scan
joint space narrowing, subchondral bone erosions, and
a b
Fig. 2.6 (a) Plain radiography: distended suprapatellar uptake at right knee on MIP image. (c) Intense FDG
bursa without evidence of bone lesion. FDG PET/CT after uptake in right knee joint along synovial lining without
surgical pus drainage and irrigation: (b) intense FDG evidence of bone involvement on CT and PET/CT images
Case 2.6 ral head and the greater trochanter of the left
A 79-year-old woman spontaneously developed femur. 99mTc-HDP bone scintigraphy showed
left hip pain a week ago. Operative findings were periarticular increased bone uptakes in the left
necrosis of the greater trochanter of the left acetabulum, left femoral head, and trochanteric
femur, multiple abscess pockets around the area. A round photopenia was in the intertrochan-
greater trochanter, and granuloma and inflamma- teric area, which is corresponding to intramedul-
tory tissue around abscess. The pathologic report lary abscess in the femur on MRI (Fig. 2.7).
of hip joint biopsy was active granulomatous
inflammation with caseous necrosis. MTB-PCR Teaching Points
result was positive. • Three-phase bone scintigraphy is a good
Plain radiography of the left hip showed peri- modality showing active tissue inflam-
articular radiolucencies in the acetabulum, the mation and bone change. However, it is
femoral head, and the proximal femur. Mixed nonspecific to detect a infection and is
erosive and sclerotic bone lesions were in the only representing tissue hyperemia and
greater trochanter. FS T2W coronal MRI showed bone turnover. So, similar findings can
heterogeneous intermediate to high signal inten- be demonstrated in aseptic other joint
sity of bone marrow changes in the acetabulum disease.
and in the head and intertrochanteric area of the • Mild periarticular increased bone uptake
left femur. Fluid accumulation (cold abscesses) may be a finding of reactive bone change
of mixed high and low signal intensity was in the resulted from synovial hyperemia or
left hip joint space and in the femur, suggesting reactive bone marrow edema.
tuberculous arthritis combined with tuberculous • Associated cortical bone destructions in
osteomyelitis. Fluid accumulations were also the course of the disease can be repre-
noted in para-articular soft tissues and in the tro- sented as focal intense bone uptakes.
chanteric bursa. Bone erosions were at the femo-
26 Y. M. Han
a b
Fig. 2.7 (a) Plain radiography: periarticular radiolucen- space, proximal femur, trochanteric bursa, and para-
cies (arrows) in acetabulum, femoral head, and proximal articular soft tissues. (c) Bone scintigraphy: periarticular
femur. Mixed erosive and sclerotic bone lesions (arrow- increased bone uptake at left hip with small round photo-
heads) in greater trochanter. (b) FS T2W MRI: bone mar- penia in proximal femur, corresponding to intramedullary
row changes in acetabulum and proximal femur with bone abscess
erosions. High signal intensities of cold abscesses in joint
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Inflammatory Arthritis
3
Ju Won Seok
Abstract Keywords
Inflammatory arthritis is a joint inflammation Rheumatoid arthritis · Ankylosing spondylitis

caused by an overactive immune system. It Gout · Synovial hyperplasia · Joint effusion
usually affects many joints throughout the Bone erosions · Tenosynovitis
body at the same time. Inflammatory arthritis
is much less common than osteoarthritis,
which affects most people in their later stages 3.1 Ankylosing Spondylitis
of life. The major types of inflammatory
arthritis including rheumatoid arthritis, sero- 3.1.1 Etiology and Clinical
negative spondyloarthropathies (ankylosing Significance
spondylitis), and crystal-induced arthritis
(gout and pseudogout) will be presented in Ankylosing spondylitis (AS) is a chronic inflam-
this chapter. matory disease that affects the sacroiliac (SI)
Clinical symptoms, physical examination, joints and/or spine in particular. AS is often more
blood tests, and imaging techniques, including common in men and becomes symptomatic in the
plain radiography, ultrasonography of joints, second or third decades as lower back pain and
CT, and MRI, are essential to make an accu- spinal immobility [1]. In addition, approximately
rate diagnosis. Bone scintigraphy is frequently 90% of AS patients are HLA-B27 positive.
used in the workup of patients with inflamma- Though the pathogenesis of AS has not yet
tory arthritis, because it is not specific, but been fully understood, it is now clear that spinal
sensitive in the detection of inflammatory bone formation in AS is a post-inflammatory tis-
joint diseases. sue remodeling reaction. Enthesitis is an impor-
tant pathologic feature of AS and believed to
represent the primary pathogenic process in such
a group of disease [2]. Studies have shown pre-
disposing factors such as genetic background,
microbial infection, endocrine abnormalities, and
immune responses associated with the occur-
J. W. Seok (*) rence of AS [3–5].
Department of Nuclear Medicine, Chung-Ang
University, College of Medicine,
Seoul, Republic of Korea
e-mail: [email protected]
30 J. W. Seok
3.1.2 Radiographic Imaging

Teaching Points
Symmetrical and bilateral sacroiliitis is usually • Bone scan may be helpful with ambigu-
the first manifestation. The sacroiliac joints were ous findings on SI joint in conventional
first widened, and subchondral erosions, sclero- imaging methods.
sis, and proliferation on the iliac side of the SI • Qualitative evaluation of radionuclide
joints were detected. Early spondylitis, along accumulation in SI joints can be difficult
with reactive sclerosis, is characterized by small due to normal uptake at this location.
erosions at the corners of vertebral bodies. AS is Therefore, quantitative analysis may be
the most common cause of vertebral body squar- more useful.
ing. It usually includes several steps and gener-
ally begins in the lumbar spines and precedes the
bamboo spine. Case 3.1
Chronic structural changes such as erosions, A 16-year-old man with left wrist and right hip
subchondral sclerosis, and bony ankylosis are pain that started several months ago. Bone scan
better observed in CT. MRI may play a role in shows markedly increased uptake in the left wrist
early diagnosis of sacroiliitis. MRI is more sensi- and right sacroiliac joint. MRI shows bone mar-
tive in detecting inflammatory changes such as row edema around the right sacroiliac joint, rep-
bone marrow edema, synovitis, and capsulitis. resenting osteitis with erosions, synovitis, and
Bone scan may be helpful in selected patients capsulitis, suggesting right active sacroiliitis. He
with normal or equivocal findings on sacroiliac was clinically diagnosed with ankylosing spon-
joint, and quantitative analysis by uptake ratio of dylitis (Fig. 3.1).
SI joint to sacrum may be useful.
Fig. 3.1 Bone scan images show increased uptake of left wrist and right sacroiliac joint, and MRI also shows findings
suggesting sacroiliitis
3 Inflammatory Arthritis 31
Case 3.2 3.2 Rheumatoid Arthritis

A 17-year-old man with persistent bilateral hip
and back pain. Radiologic imaging shows bilat- 3.2.1 Etiology and Clinical
eral sacroiliitis. Bone scan shows increased Significance
uptake in both SI joints. The uptake ratio of sac-
roiliac joint to sacrum was measured high 2.46 Rheumatoid arthritis (RA) is a systemic autoim-
on the right and 2.86 on the left (normal value, mune disease characterized by inflammatory
within 1.2), meaning that uptake of SI joints arthritis and extra-articular involvement [6].
increased due to sacroiliitis (Fig. 3.2). Although the cause of RA is unknown, a genetic
predisposition and an environmental trigger were
Case 3.3 generally considered to have led autoimmune
A 35-year-old man with ankylosing spondylitis resactions [7]. Activation and accumulation of
has had stiffness and pain in his back since he CD4 T cells in the synovium cause a continuation
was 20 years old. He had never been treated, and of inflammatory reactions [8]. An inflammatory
the pain has worsened recently. Radiographic reaction induces pannus formation. Pannus grad-
imaging shows bilateral sacroiliitis. Bone scan ually erodes at the bare area at first, followed by
shows increased uptake in both sternoclavicular the articular cartilage, and it causes fibrous anky-
junctions and both SI joints. He was clinically losis which becomes an ossfication [9].
diagnosed with SAPHO syndrome accompanied The most common clinical manifestation of
by ankylosing spondylitis (Fig. 3.3). RA is the polyarthritis of the small joints of the
Fig. 3.2 Sacroiliitis is observed in both sacroiliac joints on X-ray images, and increased uptake of both sacroiliac joints
is also observed on bone scan images
32 J. W. Seok
Fig. 3.3 Bone scan images show increased uptake in both sacroiliac joints. Characteristically, increased uptake in both
sternoclavicular junctions is observed in bone scan images
hands: proximal interphalangeal (PIP), metacar- proximal joints in a bilaterally symmetrical dis-
pophalangeal (MCP) joints, and wrist. Other tribution. The acquired changes of RA are sub-
joints that are generally affected include wrists, chondral cyst formation, hitchhiker’s thumb
elbows, shoulders, hips, knees, ankles, and meta- deformity, scapholunate dissociation, and anky-
tarsophalangeal (MTP) joints. The arthropathy losis. The feet are the same as the hands, and PIP
has a typical inflammatory phenotype with joint and MTP joints are preferred.
stiffness, reduced range of motion, and decreased Ultrasonography can evaluate soft tissue man-
function. ifestations such as synovial proliferation and
inflammation of the superficial joints, tenosyno-
vitis, and bursitis [10]. MRI is particularly sensi-
3.2.2 Radiographic Imaging tive to the initial and subtle characteristics of
RA. Characteristics of RA, which are best dem-
Radiographic features of RA are marginal ero- onstrated by MRI, include synovial hyperemia,
sions, soft tissue swelling, osteoporosis, and nar- synovial hyperplasia, pannus formation, reduc-
rowing of joint space. Diagnosis and follow-up of tion in the thickness of cartilage, subchondral
patients with RA generally include images of cysts and erosion, juxta-articular bone marrow
hands and wrist. The disease tends to affect the edema, and joint effusions [11].
phalangeal joints of both hands. Bone scan shows

Teaching Points increased uptake in both hands, wrists, elbows,
• Bone scan appeared to be a more sensi- both knees, ankles, and both feet, suggestive of
tive method for detecting inflammatory polyarthritis (Fig. 3.4).
joint disease than conventional imaging
methods and more sensitive than clini- Case 3.5
cal evaluation in diagnosis of joint A 50-year-old woman presented with pain in the
inflammation. wrist and knee joints. Radiologic imaging of
• The occurrence of erosion of RA can be both feet showed bone erosions at left first inter-
predicted through bone scan. phalangeal joint, both third and fourth metatar-
• When the high activity persists, erosions sophalangeal joint, and left fifth
were most likely to occur in joints show- metatarsophalangeal joint, subluxation of right
ing high radionuclide uptake. third and left fourth metatarsophalangeal joint,
and soft tissue swelling around left fifth metatar-
sophalangeal joint. It suggested rheumatoid
Case 3.4 arthritis. There was no significant bony abnor-
A 52-year-old woman presented with pain in all mality on both knees and both hands, except for
finger joints and wrists lasting more than 10 years. joint effusion of the left knee. Bone scan shows
She had pain, swelling, and stiffness in the increased uptake in both wrists; both knees; right
knuckles in the morning, which lasted for more first, second, and third metatarsophalangeal
than 1 h. Plain radiograph of both hands shows joints; and left third, fourth, and fifth metatarso-
degenerative change and erosions on metacarpophalangeal joints (Fig. 3.5).
Fig. 3.4 Increased uptake of both wrists; the second and third, and fourth proximal interphalangeal joints of the left
fifth metacarpophalangeal joints; the third, fourth, and fifth hand; both ankles; the first, second, third, fourth, and fifth
proximal interphalangeal joints; and the second and third metatarsophalangeal joints of the right foot; and the first,
distal interphalangeal joints of the right hand; the first, sec- second, third, and fifth metatarsophalangeal joints of the
ond, and third metacarpophalangeal joints and the second, left foot are observed in bone scan images
34 J. W. Seok
Fig. 3.5 Bone scan images show increased uptake of multiple metatarsophalangeal joints of both feet, and X-ray
images also show bone erosion of multiple metatarsophalangeal joints of both feet
Fig. 3.6 Severe deformity is also observed in X-ray imaging in both wrist joints where increased uptake is observed in
bone scan imaging
Case 3.6 increased uptake in both wrists, left first metacar-

A 61-year-old woman was diagnosed with rheu- pophalangeal joint, and fourth proximal interpha-
matoid arthritis 10 years ago due to multiple joint langeal joint of the left hand (Fig. 3.6).
pains and was treated at another hospital, but did
not improve, and was admitted to the outpatient Case 3.7
hospital. Radiologic imaging shows severe defor- A 47-year-old woman was admitted with wrist
mity on both wrist joints. Bone scan shows pain lasting more than 1 year. Radiologic imag-
Fig. 3.7 In both wrist joints, bone scan images show increased uptake, and severe deformity was observed in X-ray
images
ing suggested advanced rheumatoid arthritis on tion, and swollen joints, typically in the lower
both wrists. Bone scan shows markedly increased limb, and classically affects the first metatarso-
uptake in both wrist joints (Fig. 3.7). phalangeal joint. Gout accumulated monoso-
dium crystals in tissues; it causes arthritis, soft
tissue mass, nephrolithiasis, and urate nephrop-
3.3 Gout athy [14].
The main risk factor is hyperuricemia, which
3.3.1 Etiology and Clinical can leave uric acid crystals such as needles inside
Significance joints [15]. The main symptom is joint pain that
appears often first on the big toe. Other joints that
Gout is a metabolic disorder [12]. However, may be affected include ankles, feet, knees, and,
since clinical presentations are very similar to in severe cases, wrists, elbows, and fingers [16].
arthritis, gout is also classified as a form of crys- A similar condition, known as pseudogout, has
tal-induced arthritis [13]. Acute gout arthritis similar symptoms. In both conditions, white
represents a monoarticular redness, inflamma- blood cells surround chemical crystals that cause
36 J. W. Seok
inflammation. In pseudogout, the associated Case 3.8

crystals are formed from calcium pyrophosphate A 34-year-old man was admitted with a 1-month
dihydrate, rather than uric acid as in gout, and history of pain in the ankle joints followed by
knee joints are primarily affected. involvement of both first metatarsophalangeal
joints. Radiographs show erosive changes on the
right medial hallux sesamoid bone and small ero-
3.3.2 Radiographic Imaging sion on the left first proximal phalangeal base.
Bone scan shows increased uptake in both first
Although not all patients progress to this stage, metatarsophalangeal joints. Ultrasound image
characteristic radiologic changes occur in the shows synovial thickening and joint effusion
chronic stage. Small joints of the hands and feet with echogenic nodular lesions of medial capsule
are preferred. The earliest change is the swelling of bilateral metatarsophalangeal joints. It sug-
of soft tissue. At a later stage, erosions occur gested gout arthritis (Fig. 3.8).
that may be far from the articular cortex. These
erosions are well defined, often sclerotic and Case 3.9
with edges, often protruding edges. It is because A 48-year-old man presented with sudden right
there are urate sediments in the bone. These foot pain. Radiographic imaging shows degenera-
sediments are so large that they can cause exten- tive change and soft tissue swelling on the right
sive bone destruction. Usually, there is no osteo- first metatarsophalangeal joint. Bone scan shows
porosis. Due to the collection of sodium urate increased uptake in the right first metatarsophalan-
known as tophi, localized soft tissue lumps may geal joint. Ultrasound image shows echogenic foci
occur in the periarticular tissues. The swellings and capsular thickening on right first metatarsopha-
may be large and sometimes calcification may langeal joint; it suggested gout arthritis (Fig. 3.9).
be shown [17].
Although there may be changes in appear- Case 3.10
ance, the tophi are hyperechoic and heteroge- A 41-year-old man was diagnosed with gout at an
neous and tend to be poorly defined contours in outside hospital and was admitted. He complained
ultrasound. CT and MRI can distinguish between of pain in both knee and ankle joints. Radiographic
urate mineralization and calcification and can be imaging shows moderate osteoarthritis on both
useful if clinical and biochemical presentations knee joints, but no abnormal findings were found
are atypical. in both ankles. Bone scan shows increased uptake
in the right knee and right ankle joints. Ultrasound
image shows echogenic tophi on medial aspect of
Teaching Points both ankles and right knee (Fig. 3.10).
• Bone scan has high sensitivity to osse-
ous abnormality detection, but the scin- Case 3.11
tigraphic findings in gout are often A 47-year-old woman was admitted with pain in
non-specific. both feet lasting for 1 year. Radiographic imag-
• Asymmetrical, bilateral, and multifocal ing showed diffuse osteopenia and osteoarthritis
joint involvement tends to be associated on both feet. Bone scan shows increased bone
with severe abnormal uptake area. uptake in both cuboid bones of both feet and joint
• The intense uptake usually extends uptake in the first metatarsophalangeal joint and
beyond the associated joints, because of proximal interphalangeal joints of the right foot.
the swelling of soft tissue. Ultrasound image shows mild synovitis and
echogenic change on both first metatarsophalan-
Fig. 3.8 In both first metatarsophalangeal joints, increased uptake is observed in bone scan images, bone erosion is
observed in X-ray images, and synovial thickening was observed in ultrasound images
geal joints and synovial thickening and erosive showed no abnormality on both feet. Bone scan
change with joint effusion on tarsometatarsal shows increased uptake in the right first metatar-
joints of both feet. The patient was clinically sophalangeal joint, both knee joints, and both
diagnosed with gout (Fig. 3.11). ankle joints. Ultrasound image shows large echo-
genic foci with bony erosion and synovial thick-
Case 3.12 ening and small joint effusion. CT image with
A 42-year-old man presented with unbearable uric acid spectral CT shows gout tophi on the
pain in the right first toe. Radiographic imaging right first toe (Fig. 3.12).
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the davenport. She snatched this up and, moving silently toward the
conservatory, draped it over her face and figure. The veil was of elastic,
filmy material, long and wide. It covered the girl from head to foot,
shrouding her in silver gray.
At the open door leading into the conservatory Hester paused and,
settling her ghostly draperies about her, stood still. Through the crack of the
door she could see Mrs. Baxter in the conservatory, rigid with fright, still
holding her candle and staring wide-eyed before her.
"Mother!" called the young man for the third time. "Speak to me!
Where are you?" He was stumbling about in the dark hall.
This time Eleanor heard the comforting voice of her son and tried to
answer.
"Bob!" she cried faintly, and staggered toward the library door. "Bob!"
she called, louder, and took a step into the shadowy room. Then, as the
candle light flamed forward, she came, suddenly, face to face with a still
figure, a shrouded, sinister woman in gray. It was too much. It was more
than Eleanor Baxter could bear. With a stifled moan she sank down on the
library floor and was conscious of nothing more until she opened her eyes
weakly and found Bob bending over her.
CHAPTER XIII
FIRST AID TO THE INJURED
As regards the gray lady whose seeming apparition had spread such
wide alarm, anyone curious to know something of the ghostly Ladye Ysobel
Ippynge (she was believed to have been poisoned by her husband, Sir Gyles
Ippynge, Knight, and first earl of Ippingford in the early part of the twelfth
century) will find a true account of her pious life and tragic death in a
volume entitled, "Kronicon Uxorium," in the Bodleian library of Oxford,
written by the monk Abel of Ipswich and printed in London in 1529.
The pious Lady Ysobel would have been sore distressed had she known
what a fearful pother her counterfeit presentment (by Hester Storm) would
one day cause. What had really happened was perfectly simple, although
the consequences were complicated and far-reaching. When Hester came to
the bottom of the stairs she had turned out of her way in the darkness and
passed close to a pedestal supporting a suit of armor that kept impressive
guard there in the ancestral hall. So close had she passed that the cord of her
electric lamp had caught on one of the links in the coat of mail, whereupon,
in her plunge away from this ghostly restraint, she had toppled over the
grim warrior, pedestal and all, with a crash and rattle of his various
resounding parts that had alarmed the entire establishment. And this uproar
had terrified Mrs. Baxter all the more because she was already quivering
with superstitious dread after reading that creepy tale of Bulwer Lytton's,
"A Strange Story"; in fact, it was to seek relief from this obsession that the
agitated lady had gone downstairs for some sulphonal sleeping tablets that
she had left in the conservatory. And the silent, silver-draped apparition,
looming suddenly in the shadows, had done the rest.
For the Storm girl it was an incredibly narrow escape. A mere matter of
seconds decided her fate. If young Baxter had carried a candle she would
have been discovered. If Mrs. Baxter's candle had not been extinguished by
that lady's fall she would also have been discovered. As it was, Hester had
time to flee across the dark conservatory and out into the park (by the
unlocked door) before Bob, blundering and stumbling through the hall and
library, had reached his fainting mother.
It may be added that Hester's quick impersonation of the gray lady was
not entirely inspirational. She had heard old Mrs. Pottle refer to the specter
that haunted Ipping House that very evening; and, while she watched at the
lodge for the Baxter automobile, her thoughts had turned to the shivery
legend when she heard An Petronia, with motherly tenderness, putting to
bed the four "Pottles" (who seemed wakeful) and assuring them that "the
dray lady would tum and det them," if they didn't go to sleep.
It must not be supposed, however, that either the gray lady or her
understudy, Hester Storm, was responsible for the series of happenings at
Ipping House that ended in converting that comfortably appointed English
home into as uncompromising a wilderness, as far as the relatives were
concerned, as the most resourceful Swiss Family Robinson could hope to be
wrecked upon. There was another agency at work; to-wit, Parker.
Parker, at this particular time, was the only indoors man at Ipping
House, his rank being that of butler, footman, and valet combined. For
sympathetic and politic reasons, Parker had given notice on the very same
day that Mrs. Edge had received her congé from Mr. Baxter.
In appearance Parker was of the candle-complexioned, patent-leather-

haired type that nature seems to have distributed impartially between the
pulpits and pantries of Great Britain. Parker's greatest personal asset was a
subtle fluidity of temperament which caused visitors at a house where he
had been engaged only the week before to believe that he was an old family
retainer. It was to this priceless gift that Parker owed his success in New
York, where he had spent ten profitable years and adorned many expensive
houses, seldom staying long in any one place as new accessories to social
elegance outbid each other for his services. It was in New York that Parker's
face took on its expression of impeccable superiority, the envy of more than
one bishop, an expression acquired through his practice of combining with
his office of butler (for an extra charge, of course) that of private tutor of
social usages to his employers.
In the eyes of Mrs. Edge, and to quote her own words, Parker was the
"cream of gentlemen." Between Mrs. Edge and the "cream of gentlemen"
there was an understanding. When the Baxters returned to New York in the
autumn and the house would be closed for the winter, a small but desirable
hotel at Inwich (the next village beyond Millbrook) would be reopened
under the management of Mr. and Mrs. Parker.
Hiram Baxter, in spite of his homely American speech, which grated

painfully on the butler's fine cockney ear, somehow commanded the respect
of this "cream of gentlemen," who felt that there was good material in him.
He would like to have taken Baxter in hand. He longed to tell him that
detachable cuffs and collars were not permissible; that a black bow tie, if
one must wear such a thing in the daytime, should not have its ends tucked
under the flaps of the collar. Twice Parker had deliberately hidden the silver
clasps with which Hiram suspended his serviette to the lapels of his coat.
"It's fortunate they don't have no English visitors, leastways none that
matters," had been Parker's reflection. Had it been otherwise his sense of
fastidious shame would have compelled him to give notice. Not even that
'66 brandy, upon the question of whose merits Parker and Anton were in
such perfect accord, could have induced him to stay.
And now he was turning his back on these liquid joys and two months'
wages into the bargain. To be separated from Mrs. Edge was out of the
question. She was his fiancée, also the lease of the "Golden Horseshoe" was
in her name. The wily Parker, however, saw in the ghost incident a way of
visiting his resentment on the Baxter household, and he set about it at once.
At the time of the night alarm Parker had been the first to reach the hall
from the servants' wing, and, striking a match, had discovered the figure in
armor lying on its face. With an instinctive alacrity, born of former kindly
and remunerative ministrations to elderly gentlemen who had "dined,"
Parker lifted the helpless dummy to his feet and replaced the helmet, which
had rolled some distance along the oak floor.
A moment later, when Bob appeared, supporting his mother to the

stairs, the butler heard Mrs. Baxter exclaim with hysterical triumph: "There,
you can see for yourself, Bob, it wasn't the armor; it's standing up—it never
fell down at all——"
Bob raised his candle to inspect the warrior. "Did you pick up the armor,
Parker?" he asked.
"No, Mr. Robert; it was standing up just like it is now, sir."
"You can go back to bed, Parker. I'll take a turn round the house myself.
Good-night."
"Good-night, sir; thank you, sir."

The next day at noon the cook and the first and second housemaids gave
three days' notice. It was thought advisable not to tell Eleanor, and, after a
consultation with Hiram, Betty engaged a new cook and one housemaid by
telephone from a London agency.
That afternoon the cook confided to the laundress, in a frightened

whisper, that she had been told in strict secrecy by Parker, who got it from
Gibson, Mrs. Baxter's maid, that Mrs. Baxter had a white mark on her
forehead she would carry to her grave, made by the icy fingers of the Gray
Lady. The story spread among the servants like an epidemic.
As night came on the last remnant of courage accumulated in the

daylight oozed away, the frightened females refused to be separated and
passed the night on sofas and chairs in the servants' parlor.
As for Mrs. Baxter, the shock she had received was no mean tribute to
Hester's histrionic power. Nothing could remove from Eleanor's mind the
conviction that she had actually beheld the supernatural shape of Lady
Ysobel Ippynge, dead and buried these hundreds of years.
Mingled with her physical distress, there was a childish sense of outrage
in that, having survived a unique and painful adventure, she should, by its
belittlement, be robbed of the distinction she felt to be her due.
"If," reasoned the aggrieved lady, "the shock to my nerves isn't proof
enough that I have really seen a ghost, then it is because of my great self-
control; and all the thanks you get for self-control is to be told that you have
nothing the matter with you."
Very well, she would cease to cast this pearl of self-control before the
swine of unsympathy. She would let them know how really ill she was. And
so, aggravated by the well-meant but irritating optimism of her family,
Eleanor Baxter's "nerves" grew daily worse until, on the afternoon of her
third day in bed, Hiram telephoned to a nerve specialist in London, who
took the first train for Ippingford and informed the suffering lady, after a
careful examination, that she was on the verge of complete nervous
prostration. This was the first sensible remark Eleanor had heard for a
week.
"Don't give yourself a moment's worry, Mr. Baxter," said the doctor, as
Hiram put him aboard the train. "All your wife really needs is a change of
air. Better take her down to Brighton."
"Hm! Brighton! Swell place by the sea, ain't it?"
"It's quite a fashionable resort, just what Mrs. Baxter needs."
"No ghosts there?" chuckled the big fellow.
"No ghosts," laughed the doctor, as he waved farewell.
Hiram sent Bob back in the automobile and walked home. With this
mention of Brighton there had come to him an idea that he wanted to work
out, an idea having to do with his general plan of reducing expenses. If a
stay at the seashore was what Eleanor needed, why not give her enough of
it, say a fortnight or a month? And, if they were going to be away a month,
why not close Ipping House and get rid of a raft of servants? And why not
—— then frowning he thought of his relatives and of his favorite purpose
regarding them as he had outlined it to the Bishop of Bunchester, and then
he thought apprehensively of Eleanor.
"Holy cats!" he muttered. "It's goin' to be a job, but I'll do it."
That evening, after dinner, he went to his wife's room and asked her
carelessly how she would like to go down to Brighton for a week or two.
Eleanor beamed. She would love it. Was he really going to take her? How
soon? Could they stay a whole fortnight in Brighton?
Hiram assured her most considerately that they could stay a whole
month in Brighton, if she wished. And they would start the next day. She
had been through a great strain. It was no joke to see a ghost, he understood
that. They ought to have known better than to take a house that had a ghost
in it. And then, as tactfully as he could, the old boy came around to his
point that it might be just as well to close Ipping House and—and give the
ghost a rest.
Eleanor's eyes narrowed dangerously as she watched him from her lace
pillow.
"Close Ipping House?" she repeated in a cold, even tone. "Do you
realize what you are saying?"
Hiram took off his glasses and polished them with his handkerchief,
first blowing on them deliberately.
"Sure I do; that's why I'm sayin' it. If we shut this house we can fire the
servants, all of 'em; then, when we come back we can get new ones, half as
many and twice as good. Don't look at me that way, dearie. I hate like
everything to disappoint you, but——" he reached over and stroked her
white hand tenderly, "you know what I said about expenses? Well, I meant
it then and I mean it now. We've got to economize."
"What about my relatives? Our guests?" the wife demanded angrily.
"I guess your relatives'll have to take their chances in a new deal,
Eleanor. I'm goin' to have a little talk with 'em to-morrow morning. I told
'em at dinner. Don't worry, I ain't goin' to say a thing but what's for their
good. Bet ye three dollars and a half, when ye hear my little speech—
"Hear your speech?" she blazed. "Do you think anything could induce
me to be present while you humiliate members of my family? I think it's
abominable."
"Hold on! There ain't anything humiliating in a little honest work."
"Work?" she gasped. "Hiram, you don't mean—you're not going to put
my relatives—to work?"
Hiram shifted his legs with exasperating calmness, pulled at his short,
gray mustache, and was about to reply, when Robert strolled in cheerily and
went at once to Eleanor's bedside.
"How's the little mother to-night?" he asked affectionately. Whereupon,

to his surprise and to Hiram's great discomfiture, the lady burst into a flood
of tears.
"I'm so unhappy," she wailed. "Your father is treating me most—

unkindly and—and——" her words were lost in hysterical sobbing.
Whereupon Baxter stalked out of the room like a rumpled

Newfoundland dog, leaving Bob to administer filial comfort and smelling
salts, the result being that Eleanor was presently able to give her a son a
tearful version of Hiram's iconoclastic purposes. Bob listened with an
amused and incredulous smile.
"Don't you know, Mother," he reasoned, "that Dad's bark is always

worse than his bite? He won't close Ipping House! not a bit of it. I'll talk to
him and—what you need is sleep, especially if you're going to Brighton to-
morrow."
"I suppose you're right," sighed Eleanor. "You're a dear boy, Bob. Send
Gibson here. Tell her to bring a hot water bag and my sulphonal tablets.
And do speak to your father. Tell him I can't bear it if he closes Ipping
House."
"I'll tell him. Good-night, little Mother. There! It's going to be all right."
He kissed her lovingly and stole out of the room.
A few moments later young Baxter joined his father in the library,
where the old man was frowning over important papers that he had brought
up from town with him that evening. Things were going badly, the news
from America was most unsatisfactory, and the father and son, weary and
troubled, sat discussing it until long after midnight.
"There's some deviltry behind all this," declared the grizzled old fellow,
pounding his fist on the table. "There's crooked work in this copper
campaign. Why, that Henderson outfit seems to know what we're doing
every day, just as if they had eyes in this room. I tell you there's a leak, Bob,
but——" he glowered about the spacious walls under his heavy, black
brows.
"Are you sure of this new secretary?" whispered the son.

Hiram's eyes softened, as they rested on the winding stair. "Am I sure of
her? Sure of her?" Then with a chuckle: "Say, what do you think of my new
secretary?"
Bob answered quite seriously: "She seems to be a nice girl, but she's too
pretty."
"Think so?"
"I don't believe in very pretty girls for business positions."
"Don't, eh? Well, you can take it from me, my boy, that this partic'lar
pretty girl is all right."
Bob glanced at his watch, then rose and stretched himself.
"Half-past two! We can't do any more to-night, Dad. By the way," he

suddenly remembered his promise to his mother, "you're not thinking of
closing Ipping House?"
Hiram was silent a moment, then, slipping his thumbs into the arm-
holes of his waistcoat, he spoke with a wise drawl.
"Bob, after you've been married a while you'll find that a man thinks a
lot o' things and then, when his wife gets at him with the water-works, why
he just takes it out in thinkin'."
"Then Ipping House stays open—just as it is."
"There may be some modifications in the 'just as it is' part of it, but—
well, yes, Ipping House stays open."
"I'm glad of that. And the relatives? You're not really going to put the
relatives to work, are you?"
Hiram closed his jaws with a vigorous snap. "Am I? You just show up
in this library to-morrow morning right after breakfast and watch me give
the English aristocracy a little of Hiram Baxter's first aid to the injured.
Good-night, Son."
CHAPTER XIV
THE PARABLE OF THE COCOANUT PIE
There was fluttering anticipation among the relatives as they gathered in

the breakfast room the next morning and dallied with broiled kidneys and
anchovy toast while awaiting Baxter's summons. Which came presently
when Hiram, red-faced and genial of visage, opened the door.
"If you folks don't mind," he said, "I wish you'd join me in the library
for a little friendly talk."
At last the great moment had come, and, one by one, the relatives
passed through the hall into the room beyond, each showing in face and
manner an overbubbling delight at the thought of the benefits they expected
to receive from Cousin Hiram. And, one by one, they seated themselves in
the stiff, high-backed chairs that were ranged along the wall. Baxter settled
himself on the corner of the davenport and faced them. His eyes were
cheerful, his smile was cordial; there was not the least indication of what
was coming.
"Make yourselves comfortable, friends," began Hiram. "I've got a few

things to say, and ye might as well take it easy."
There was a shifting of positions, a little expectant coughing, and then,

just as Baxter was about to begin, Harriet Merle prodded Horatio, who was
staring absentmindedly before him.
"Horatio!" she whispered.
The curate came to himself with a start, blinked rapidly behind his
glasses, and then, remembering the duty his wife had put upon him, rose
solemnly to his feet and, in his most clerical manner, addressed Hiram
Baxter.
"Ahem! Mr. Baxter! In the name of the relatives gathered here, allow
me to extend to you our most cordial welcome on this occasion of your
return to England, together with the expression of our gratitude for your
large and unfailing generosity in the past and—er—ahem!"
"Hear, hear!" applauded Lionel.
But Hiram lifted a hand for silence. "One moment, Brother Horatio," he
drawled. "Before ye wind up yer speech, ye'd better let me make a few
remarks. Ye may want to change yer peroration."
"How delightful!" murmured Harriet.
"Go on, Cousin Hiram," urged Kate.
"Hear, hear!" repeated Lionel.
"Ahem!" coughed the curate and sat down.
"I've called you people in here," continued Baxter, "to tell ye something
that I've been thinkin' about fer quite a while. We're goin' to Brighton to-
day, Eleanor and me, fer a couple o' weeks—this ghost business has broke
Eleanor up a good deal—and I want to get this thing off my chest before I
leave. Yer all good friends o' mine and yer all more or less in hard luck.
Seems like things naturally go wrong with ye—it's been so fer years, ever
since I've had the honor o' belongin' to this family. Well, a man hates to see
his wife's relations suffer and I've tried to do what I could, but—I'm here to
tell ye now that I don't feel as if I've ever done the right thing by ye. No, sir.
All these years I've tried to help ye out of yer troubles, but I've never turned
the trick."
"Oh, I say!" protested Lionel.
"You've been splendid," Kate declared.

"We wouldn't have you any different, dear Cousin Hiram," beamed
Harriet.
Baxter paused a moment and adjusted his spectacles. "Think I'm a pretty
good feller, don't ye? Well, yer wrong. Look at my friend, Fitz-Brown, my
wife's second cousin once removed. Up to his ears in debt—always has
been. Ain't that a shame! My wife's second cousin once removed!"
The old boy leaned forward earnestly, his big, strong chin on his big,
strong hand and in his kindly, homely way addressed the gentleman in
question who was pulling fiercely at his yellow mustache.
"Now, friend Lionel, I'm goin' to show ye how ye can always have
money enough and never have any more debts or bother."
This roused the monocled one to genuine enthusiasm. "I say, I'll be
awfully pleased," he responded.
"I'll do it. And I'm goin' to show you," Hiram Baxter turned sharply to
the curate, "how you can cure that tired feelin' and hold a preachin' job for
more'n five consecutive minutes."
"Oh, thank you, sir," murmured Horatio.
"And I'm goin' to show you ladies how to be happy. Yes, sir. Trouble
with you is yer bored to death. That's why ye want to go kitin' around to
Monte Carlo and Jerusalem. I'll fix it so ye can't ever be bored."
"I wish you could," laughed Kate.
"My dear Countess," reproved Harriet, "if Cousin Hiram agrees to do a

thing you can depend upon him absolutely."
"It ain't necessary to go into details, but each one of you knows what
ye've had from me straight and regular every year for the last five years. It
makes quite a total, ten thousand pounds or more, fifty thousand dollars that
I've spent tryin' to get you people on yer feet, and I ain't ever been able to
do it. Each year yer in worse'n the year before, and it's all my fault. Want to
know why? Because I've been tryin' to help ye on the European plan, which
ain't worth shucks; but I've had my eyes opened, and now I'm goin' to
change and help ye on the good old-fashioned American plan, warranted
never to fail."
"Yes?"
"Tell us!"
"Please tell us!"
"Hear, hear!" buzzed the eager chorus.
Then came the first intimation of the truth, slowly and smilingly
delivered, but bringing shattering disillusion, nevertheless, to the trusting
relatives: "The American plan of helpin' people consists in showin' 'em how
they can help themselves."
The effect came gradually in a movement of general surprise and

consternation.
"Oh, I say!"
"But——"
"You don't mean—you surely don't mean——"
"Tell ye exactly what I mean. Yer all nice people, but ye've been trained
wrong. Your idea is to sit in the sunshine and let somebody shake plums
into yer lap, which is all right if ye can find a feller to do it, but I'm tired o'
shakin' plums and the tree's pretty well skinned, so——" Here he turned to
the countess and Harriet with his most ingratiating smile: "Ladies, I want to
ask you a question. Suppose you were on a desert island and were gettin'
terribly hungry, and suppose ye looked up and saw some nice, ripe
cocoanuts waitin' to be picked. You'd say to yourselves: 'Them cocoanuts
look awful good,' and ye'd ring like fury for the butler and the maid to come
and pick 'em and make 'em into cocoanut pies. But the butler and the maid
wouldn't show up, because yer on a desert island—uninhabited. See? So
after a while ye'd get tired o' ringin' and ye'd say to the countess——" here
he beamed on Mrs. Merle, "'Countess,' ye'd say, 'it ain't according to Hoyle
fer ladies to climb cocoanut trees, but this is a case of hustle or starve, so
we'll flip up a cent to see which one of us boosts the other into them
branches.'"
"Never," declared the curate's wife, scandalized.
"Yes, ye would!" pursued Hiram. "And before night ye'd be eatin' the
finest cocoanut pie ye ever tasted, for——" he paused and then added with
his most impressive drawl: "Take it from me, ladies, there ain't no pie in the
world like a self-made pie."
This statement was received in silence, in thin-lipped, despairing

silence. Slowly but surely the relatives were beginning to get dear Cousin
Hiram's idea.
"Ahem! Mr. Baxter!" coughed Horatio, rising again. "In the name of the
relatives gathered here, allow me to thank you for the beautiful—shall I say
touching—parable of the cocoanut pie. I think, however, that I voice the
desire of the relatives gathered here in asking you to make your ideas a little
clearer in their—shall I say in their immediate application?"
"All right, Brother Horatio," smiled Hiram, as the curate resumed his
seat. "I'll come down to cases. We're members o' the same family and we've
got to stand together."
"Ah!" approved Harriet.
"Just now it happens that I need your help. I've got big resources, but
I'm in a hard campaign. I've got my back to the wall fighting for my life and
—well, we'll come through all right and you'll benefit with me, but for a
while we've got to cut down on expenses and—er—you people'll have to—
er——"
The bolt was about to fall, the words were on Hiram's lips: "You
people'll have to do some work," but as he looked into the faces before him,
pathetic, incredulous, the old fellow weakened. "You people'll have to—er
—give this thing your—er—serious consideration," he substituted.
But the countess understood, and, with a little laugh and a shrug of her
shapely shoulders, she came straight to the point. "You mean we'll have to
—have to—work?"
Hiram nodded slowly.
"Understand, there's no hurry about this. I want to treat ye right. I want

to help ye. I want to see yer faces bright and yer needs provided for, but I
can tell ye this, from a long experience, that the thing in my life that's made
me happiest is the honest work I've done. Remember, things go on here in
Ipping House just the same, whatever you folks decide. If ye can't think of
anything practical to do, why, never mind. I'll stand by ye as well as I can;
but if ye could think o' something that yer fitted to do and could put yer
heart in, why it would solve your problems and it'd help solve mine. You'll
be sore on me for a while, like the kid that sputters and kicks and swallers a
quart of water when you chuck him in a pond to learn him to swim."
Harriet's face was a study in horror. "Good heavens, you're not going to
——"
"Chuck us in a pond? Eh, what?" gasped Lionel.
"No, no. I mean work is like swimmin'. Ye hate it until ye learn how and
then yer crazy about it. Why, you people'll feel just fine when ye've cut out
this bluff and fake business. Do ye know what a little useful work'll do? It'll
make men and women of ye."
"But what work can we do?" protested the countess.
"Jolly good point, that," echoed Lionel.
Hiram reflected a moment.
"I suppose there are things you folks could do, if ye had to, plenty o'
things. Maybe I'm mistaken, maybe it's a crazy idea, but——"
Here suddenly the curate spoke. "I think Mr. Baxter is quite right," he
began in a low tone vibrant with feeling.
"Horatio!" glared Mrs. Merle, but the little man faced her calmly.
"My dear, I beg you not to interrupt." Then, turning to the master of the
house: "Speaking for myself," he continued, "and not for the relatives
gathered here, I wish to say that, in view of your great past kindness, my
dear Mr. Baxter, I feel that you are justified, fully justified, in asking us to
help you meet the serious and, let us hope, temporary difficulties that beset
you. And I would remind the relatives gathered here of King Solomon's
beautiful and impressive words: 'Whoso keepeth the fig trees shall eat the
fruit thereof, and whoso waiteth on his master shall be honored.'"
There was a moment of uncomfortable silence. Disapproving as they

were, and bitterly disappointed, the relatives, in spite of themselves, were
impressed by a certain unsuspected moral strength in this gentle utterance.
"King Solomon cert'ly knew his business," approved Hiram, as much

surprised as the others at this turn of affairs.
"And I beg to suggest," proceeded Merle, appealing to the astonished

group, "as the least important and the least worthy person here, yet one who
has sincerely at heart the welfare of all, I venture to suggest that, before any
hasty words are spoken or any irrevocable action is taken by the relatives
gathered here, I would suggest, I say, that the relatives withdraw to their
rooms or elsewhere for a little—er—thought and—shall I say self-
examination?"
"Good idea! Fine idea!" nodded Baxter, and a moment later, with a
quizzical look in his cheery blue eyes, he watched the relatives file out
silently, one by one, a mighty sore bunch, he reflected, mouths down and
noses up, Horatio going last and bowing respectfully to Hiram as he closed
the door behind him.
For some moments the old man sat in the corner of the davenport,
smiling at this latest development. Who would have thought of it? The
Reverend Merle a champion of honest labor! Standin' up like a little bantam
rooster against them relatives!
Presently Bob entered, eager for news.
"Well?" inquired the son.
"Bob," drawled the big fellow, "I'll bet ye four dollars and a quarter
King Solomon wrote them proverbs o' his after he'd been worked by
relatives. Say, with a thousand wives he must have had an everlasting lot of
'em!"
An hour later the luggage cart appeared for the three large boxes, the
two steamer trunks and the assortment of Gladstone bags, hold-alls, and
dress-suit cases that Eleanor had caused to be packed for their brief and
simple sojourn in Brighton. Some of these things, it is true, belonged to
Betty, whose services were required by Mr. Baxter, and who now appeared,
ready for the journey, a radiant summer vision all in white except for a
bunch of pansies at her waist and a graceful, pale-blue plume in the wide-
brimmed straw hat that becomingly shaded her eyes.
The car drew up at the door, coughing and sputtering, with Bob Baxter
at the wheel. Hiram sat in front beside his son, Eleanor and Betty on the
seat behind. And, just as they were starting, Kate Clendennin tripped down
the steps and, declining to squeeze in among the bags and bundles, leaped
lightly upon the footboard at Bob's side and remained there, despite
Eleanor's protest, all the way to the station.
Poor Betty! There was a moment's delay in starting the train, after the
guard had given the signal and slammed the doors, and the banished
secretary, looking backward through the window, caught a glimpse of the
departing motor as it rounded the nasturtium bed. Kate was on the front seat
next to Bob, and they both looked back, the countess laughing and waving
her hand. Then the car turned a wooded corner, and that was the last picture
—Kate and Bob together, close together, gliding swiftly, perhaps slowly,
through those leaf-arched lanes and delicious lonesome glades of the forest.
They had taken the longer way home, but there was time enough—there
was not the slightest need for Kate and Bob to hurry.
CHAPTER XV
THE FOUR POTTLES
Kate and Harriet went straight to their bedrooms, Harriet to rehearse her
part in the forthcoming scene with Horatio; Kate, in an angry fever, to ring
for Gibson to pack her boxes without a moment's delay. She rang several
times before a housemaid appeared and informed her ladyship that Gibson
was nowhere to be found. There was a suppressed eagerness about the girl,
as if she had something further to disclose, something unusual, but Kate did
not question her, and she left the room, closing the door reluctantly behind
her.
On the table near the bed lay a yellow, paper-backed book, open and
face downward, in unseemly straddle, as Kate had left it the day before to
keep the place. It was a collection of stories by a new French author. She
picked it up and began slowly turning the pages.
Still reading, she sat down on the bed. In a little while she lifted her feet
and lay back without taking her eyes from the book. Half an hour later the
yellow book lay on the floor where Kate had flung it. How could anyone
write such trash!
Alone in her room Harriet waited for Horatio. Since the tragedy of the
afternoon before, the husband and wife had scarcely spoken, and Harriet
welcomed a storm to relieve the charged atmosphere. She was ready with
her opening speech and she knew what Horatio must inevitably reply, and
she had prepared a crushing rejoinder. But Horatio did not come.
In the mournful exodus from the library the gentle curate had been the
last, holding the door open for the others, and, after softly closing it behind
him, without lifting his eyes from the ground, he had passed, unseeing and
unseen, through the hall and out into the sunlit garden.
Scarcely noticing and caring not at all where he went, Horatio found
himself in the lane, and now, while Harriet listened in vain for his shuffling
steps on the stair, the curate was a good mile and a half away in the very
heart of the Millbrook woods. He had followed at random any path that
offered; if there were a choice, taking the one with the darkling look that
might lead to the witches' hut or the cave of the gnomes.
And now, when he was beginning to feel the creepy joy of being lost,
that he had never quite outgrown, the curate came suddenly upon a bright
grassy hollow among the dark trees, guarded from view on all sides by high
ferns. The dark old beeches gathered round it and stretched their great
elbows over it as if to keep its existence secret from all the world but one
little girl. Even the sun, who was invited everywhere, was only allowed to
take furtive peeps through the green fingers of the jealous old beeches. It
was as if they said: "Go away! This little golden maid is all the sunshine we
need, thank you!" For there, in a green velvet chair formed by the twisting
mossy root of an immense beech tree, sat An Petronia.
The curate stood still in the shadow among the tall ferns, fearing to
startle her. She was listening with shut eyes and parted lips. Twice through
the green solitude sounded the long, intensely solemn note of a wood
thrush, then it was gone, leaving behind it an echo-haunted stillness.
An Petronia opened her eyes and caught sight of the curate.
"Daddy Merle!" she called to him. "Did you hear the thrush? I wonder
what he said, Daddy Merle?"
"He said, 'I wonder who that little girl is that sits all alone by herself in
my private wood?'" intoned the curate. "Aren't you afraid of getting lost?"
he said, as he descended the ferny slope to where she sat.
"I isn't losted. I tan't det losted. I has four Pottles."

She pointed to four dolls, in various stages of dilapidation, sitting stiffly
in a row in front of her, their eight feet immersed in a trickle of water that
seemed to come from nowhere and disappeared magically among the ferns,
chuckling to itself at the success of its vanishing trick.
"Dear me," said Merle, inspecting the dolls with a profound show of
interest, "I had no idea you had so many children. What are their names?"
he inquired.
"They're not children," said An Petronia, "they're Pottles. Their names

are Maffew, Mart, Loot, and this one," she picked up the least favored in
appearance of the four, "this one is Don." She caressed him tenderly. It was
plain that Don was the one she loved best, perhaps because of his great
misfortune. Don was headless.
"He had real hair once, but I losted his head," An Petronia sighed
deeply. "I wish I had all the Pottles, Daddy Merle."
"Then there are more?" asked the curate, wondering whither the child's
strange fancy was leading her.
"Of torse there is. I had a picture of them. Don't you know the twelve
Pottles, Daddy Merle?" She opened her blue eyes in pained surprise at the
woeful ignorance of this otherwise perfect old gentleman.
Then a great light burst upon Horatio Merle. "Why, to be sure, my dear!
Of course I know the twelve apos—I should say Pottles. I have known the
twelve Pottles ever since I can remember, my child. Dear me! dear me!" His
face fairly beamed with pleasure at this lucky intuition. The curate's
happiness at having reinstated himself in the estimation of his little friend
was only equaled by An Petronia's joy at the recovery of her so nearly lost
ideal.
"I just knew you knew, Daddy Merle!" she cried, and pressed her little
palms together in an ecstasy of childish delight.
"But aren't you afraid they'll catch cold?" said the curate presently, in a
tone of proper concern, as An Petronia was returning the headless John to

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Atlas of Nuclear Medicine in

Musculoskeletal System Case Oriented

Sobotta Atlas of Anatomy, Vol. 1: General Anatomy and

Atlas of Small Intestinal Disorders Integrated Case

Atlas of Diagnostic Pathology of the Cervix A Case

Yu Gi Oh 3 in 1 Edition Vol 10 Includes Vols 28 29 30

Musculoskeletal Imaging: Case Review Series 3rd Edition

Kinesiology of the Musculoskeletal System Foundations

Atlas of Diabetes Mellitus, 4e (Dec 29,

Clinical Foundations of Musculoskeletal Medicine: A

Case Oriented Approach

Yun Young Choi Jin-Sook Ryu

ISBN 978-981-19-2676-1 ISBN 978-981-19-2677-8 (eBook)

Busan, Republic of Korea Seoung-Oh Yang

Part I Inflammatory and Infectious Disorders

1 Musculoskeletal Infections�������������������������������������������������������������� 3

Part II Traumatic and Circulatory Disorders

Part III Spine and Joint Disorders

12 Knee Prostheses�������������������������������������������������������������������������������� 131

Part IV Metabolic and Endocrine Osseous Disorders

14 Metabolic Bone Disease ������������������������������������������������������������������ 157

Part V Musculoskeletal Neoplastic Disorders

Part VI Miscellaneous Features in Musculoskeletal

Young-Sil An Department of Nuclear Medicine and Molecular Imaging,

Su Jin Lee Department of Nuclear Medicine, Ajou University School of

Fig. 1.3 Pretibial soft tissue a b c

Fig. 1.10 Three-phase bone scan shows increased perfu-

1.5 Pyogenic Spondylitis bral osteomyelitis, septic discitis, and epidural

Fig. 1.13 Contrast-

Case 1.7 in the left side of screw of L3 body (Fig. 1.14c,

• SPECT/CT allows accurate anatomical involvement of bony inflammation or

References infections, particularly chronic and low-grade infec-

Septic arthritis is a painful infection in a joint Septic · Infectious · Arthritis · Tuberculous

2.2 Diagnosis Scintigraphy with 99mTc-labeled phosphonates

F-FDG PET (fluorine-18 fluorodeoxyglucose

Fig. 2.1 (a, b)

Fig. 2.3 (a) Plain

and patchy bone marrow edema. Mid-carpal Case 2.5

References 5. Eriksen EF, Ringe JD. Bone marrow lesions: a uni-

Inflammatory arthritis is a joint inflammation Rheumatoid arthritis · Ankylosing spondylitis

3.1.2 Radiographic Imaging

Case 3.2 3.2 Rheumatoid Arthritis

phalangeal joints of both hands. Bone scan shows

Case 3.6 increased uptake in both wrists, left first metacar-

inflammation. In pseudogout, the associated Case 3.8

FIRST AID TO THE INJURED

In appearance Parker was of the candle-complexioned, patent-leather-

Hiram Baxter, in spite of his homely American speech, which grated

A moment later, when Bob appeared, supporting his mother to the

"No, Mr. Robert; it was standing up just like it is now, sir."

"Good-night, sir; thank you, sir."

That afternoon the cook confided to the laundress, in a frightened

As night came on the last remnant of courage accumulated in the

"Hm! Brighton! Swell place by the sea, ain't it?"

"It's quite a fashionable resort, just what Mrs. Baxter needs."

"No ghosts there?" chuckled the big fellow.

"No ghosts," laughed the doctor, as he waved farewell.

"Holy cats!" he muttered. "It's goin' to be a job, but I'll do it."

"What about my relatives? Our guests?" the wife demanded angrily.

"Hold on! There ain't anything humiliating in a little honest work."

"How's the little mother to-night?" he asked affectionately. Whereupon,

"I'm so unhappy," she wailed. "Your father is treating me most—

Whereupon Baxter stalked out of the room like a rumpled

Busan, Republic of Korea Seoung-Oh Yang

Part I Inflammatory and Infectious Disorders

1 Musculoskeletal Infections�� 3

Part II Traumatic and Circulatory Disorders

Part III Spine and Joint Disorders

12 Knee Prostheses�� 131

Part IV Metabolic and Endocrine Osseous Disorders

14 Metabolic Bone Disease �� 157

Part V Musculoskeletal Neoplastic Disorders

Part VI Miscellaneous Features in Musculoskeletal

1.5 Pyogenic Spondylitis bral osteomyelitis, septic discitis, and epidural

2.2 Diagnosis Scintigraphy with 99mTc-labeled phosphonates

3.1.2 Radiographic Imaging

Case 3.2 3.2 Rheumatoid Arthritis