Reason: assess for osteomyelitis History: draining ulcer, plantar surface L foot, dry ulcers 3rd and 4th toes The patient has undergone amputation of the great toe through the base of the proximal phalanx. We see no signal abnormality in the first metatarsal or remaining base of the proximal phalanx to suggest osteomyelitis. The second toe has been amputated through the neck of the second metatarsal. The amputation margin appears relatively sharp and while there is mild edema-type signal within the distal aspect of the remaining metatarsal, we suspect that this is chronic in etiology, perhaps reflecting sequela of prior infection rather than acute osteomyelitis. More pronounced signal abnormality within the base of the second metatarsal as well as the middle cuneiform bone is favored to be degenerative in etiology or perhaps represent early neuropathic arthropathy. We see no ulcer or sinus tract leading to this joint to confirm osteomyelitis.There is mild deformity of the head of the third metatarsal with mild signal abnormality in the subchondral bone. Again, we favor this to be chronic in etiology perhaps reflecting sequela of prior infection rather than acute osteomyelitis as we see no sinus tract leading to the bone. Osteoarthritic changes affect the third tarsometatarsal joint. There is thickening of the skin of the third toe with ulceration dorsally. There is increased signal intensity within the distal phalanx, middle phalanx, and head of the proximal phalanx on the fat-suppressed T2-weighted images. The fat signal intensity within the middle phalanx and head of the proximal phalanx is largely preserved on the T1-weighted images and therefore this likely represents reactive osteitis. However, there is intermediate signal intensity within the distal phalanx that is suspicious for early osteomyelitis.There is mild edema-type signal intensity within the head of the fourth metatarsal which may be degenerative in etiology as we see no sinus tract leading to bone to support osteomyelitis. There is mild thickening of the skin of the fourth toe with mild subcutaneous edema. Minimal edema-type signal in the distal phalanx of the fourth toe is favored to represent reactive osteitis rather than osteomyelitis. Mild osteoarthritis affects the fourth tarsometatarsal joint.There is deformity and tapering of the fifth metatarsal, perhaps reflecting prior surgery and/or sequela of old infection. There appears to be ulceration of the dorsal aspect of the fifth toe. Abnormal signal intensity within the distal phalanx of the fifth toe, particularly on the T2 weighted images, is suspicious for osteomyelitis. Mild osteoarthritis affects the fifth tarsometatarsal joint.There is generalized edema of the soft tissues, particularly dorsally, as well as atrophy of the plantar musculature of the foot. Mild irregularity of the plantar medial skin surface at the level of the first metatarsal head may represent ulceration.
Signal abnormality affecting multiple bones as described above likely represents a combination of postsurgical changes, osteoarthritis, sequela of remote infection and reactive osteitis. However, more pronounced signal abnormality within the distal phalanges of the third and fifth toes is suspicious for acute osteomyelitis.