99-year-old female with a diabetic foot ulcer. Rule out osteomyelitis. There is ulceration of the soft tissues of the distal aspect of the great toe. Although on these images, it appears that the distal phalanx protrudes through the soft tissue ulceration, consultation with Dr. Raychaudhuri reveals that the bone does not protrude through the soft tissues nor can it be probed on physical examination. On the T2 weighted STIR sequences there is abnormal signal intensity throughout the majority of the distal phalanx. However, the signal intensity in the T1-weighted images is normal and there is no frank cortical destruction. There is signal abnormality within the subcutaneous fat, particularly dorsal to the distal phalanx, likely representing edema. The signal intensity of the proximal phalanx of the great toe and first metatarsal is normal. There is focal edema within the middle phalanx of the second toe seen on the STIR sequences with normal signal intensity on T1-weighted images. We see no adjacent ulceration to confirm osteomyelitis. The remaining phalanges and metatarsals appear normal. There is atrophy of the musculature of the forefoot.
1. Edema within the distal phalanx of the great toe on STIR sequences with normal-appearing marrow on T1-weighted images. This pattern of signal abnormality is typically seen with reactive osteitis rather than osteomyelitis, however, given the extent of signal abnormality, follow-up examination with dedicated radiographs is recommended in 7-14 days to exclude osteomyelitis.2. Nonspecific edema-type signal abnormality in the second toe only seen on STIR sequences. We see no ulceration in the surrounding area to confirm osteomyelitis.