45-year-old male patient with history of osteomyelitis status post right second toe amputation.New wound, edema. Evaluate for osteomyelitis. There is soft tissue ulceration along the ball of the foot with extensive signal abnormality in the underlying subcutaneous soft tissues. Additionally, there is diffuse edema throughout the soft tissues of the foot.As seen on the radiographs, there is dorsal dislocation of the proximal phalanx of the great toe relative to the first metatarsal. There is a small rim-enhancing fluid collection immediately plantar to the head of the first metatarsal. There is erosion of the plantar and medial aspects of the head of the first metatarsal surrounding a small intramedullary focus of near fluid signal intensity. Although there is little enhancement of the medullary bone, these findings are suggestive of chronic osteomyelitis and a small intramedullary abscess. There is proximal displacement of the sesamoid bones with surface irregularity and signal abnormality of the lateral sesamoid likely reflecting chronic osteomyelitis. Mild signal abnormality within the lateral aspect of the base of the proximal phalanx may be related to chronic osteomyelitis or reactive osteitis. Signal intensity of the distal phalanx appears normal.The patient is status post amputation of the second toe. There is a sinus tract extending from the plantar surface of the ball of foot to what remains of the head of the second metatarsal. Small rim-enhancing fluid collections surround the second metatarsal head and probably communicate with the aforementioned sinus. There is abnormal signal intensity and enhancement involving the head and diaphysis of the second metatarsal indicating osteomyelitis.As seen on radiographs, there is deformity of the head of the third metatarsal and signal abnormality compatible with chronic osteomyelitis. There is signal abnormality within the proximal phalanx of the third toe compatible with chronic osteomyelitis. Signal intensity within the middle and distal phalanges are within normal limits. There is also a small enhancing fluid collection adjacent to the head of the third metatarsal.Abnormal signal intensity and enhancement involving the head, neck, and diaphysis of the fourth metatarsal is compatible with osteomyelitis. The phalanges of the fourth toe appear normal.There is a tiny focus of edema type signal in the head of the fifth toe metatarsal which is favored to be arthritic in etiology over osteomyelitis. The phalanges of the fifth toe are within normal limits. There is also a small rim-enhancing fluid collection (4-5 mm) immediately adjacent to the lateral aspect of the base of the fifth metatarsal with surrounding inflammation. A 6-7 mm collection of fluid signal intensity dorsal to the base of the fifth metatarsal may represent a synovial cyst or ganglion.Degenerative arthritic changes affect the bones of the midfoot. There is thickening of the plantar fascia. The flexor hallucis longus tendon is also abnormally thickened likely due to a chronic full-thickness tear and becomes inseparable from the plantar fascia beneath the first metatarsal likely representing chronic scarring. There is also enhancement surrounding the flexor tendons near the first metatarsal neck suggestive of tenosynovitis. Distal to this, the tendons are not visualized and may be torn.
Soft tissue ulceration with multifocal osteomyelitis and other findings as described above.These findings were discussed with M. Jacobs via telephone at 0959 hrs. 