Findings
Plain radiograph (a) reveals lytic lesion in proximal phalanx of great toe predominantly involving proximal shaft, showing wide zone of transition, cortical breach with adjacent soft tissue thickening. Sagittal T1 (b), T2 (c), oblique axial T1 (d), oblique axial PDFS (e) and sagittal post contrast T1 MRI images of foot (f) reveal marrow edema, heterogeneous post-contrast enhancement of proximal phalanx of great toe, distal first metatarsal bones with cortical breach of proximal shaft of proximal phalanx, moderate effusion showing synovial thickening in first metatarsophalangeal joint. Mild periarticular soft tissue edema and enhancement is also noted.
Diagnosis
Chronic osteomyelitis of proximal phalanx of great toe, distal first metatarsal bone with septic arthritis of first metatarsophalangeal joint.
Summary
Prompt diagnosis of clinically suspected pedal osteomyelitis is essential to initiate early medical and surgical therapy. MRI has been shown to be the most useful imaging study because it is capable of reliably detecting primary marrow signal abnormalities and secondary bone and soft-tissue abnormalities including cortical bone destruction, cellulitis, soft-tissue ulceration, phlegmon, abscess, and sinus tracts. Some patients may be successfully treated with early antibiotic therapy. However, many patients, especially those with diabetes, may require aggressive surgical debridement or selective amputation.
Further reads
Collins MS, Schaar MM, Wenger DE, Mandrekar JN. T1-weighted MRI characteristics of pedal osteomyelitis. AJR Am J Roentgenol. 2005 Aug;185(2):386-93. doi: 10.2214/ajr.185.2.01850386. PMID: 16037509.
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