Cellulitis. Suspicious for osteomyelitis of left great toe based on x-ray. There is mild deformity of the proximal phalanx of the great toe, as seen on recent radiographs; I cannot tell if is due to prior trauma or perhaps the sequela of prior infection. There is replacement of the normal subcutaneous fat plantar to the base of the proximal phalanx with intermediate signal intensity which shows enhancement following contrast administration. There is also slight irregularity of the overlying skin surface. These findings may reflect ulceration with underlying granulation tissue, but I see no discrete sinus tract or fluid collection. There is additional diffuse enhancement of the soft tissues of the great toe compatible with the stated history of cellulitis, as well as mild diffuse edema of the forefoot, particularly along its dorsal aspect, extending along the medial aspect of the midfoot. There is also enhancement of the soft tissues immediately dorsal to the head of the fifth metatarsal, but the underlying marrow signal intensity appears normal.There is abnormal signal intensity within the base of the proximal phalanx (low signal intensity on T1-weighted images, high signal intensity on fat-suppressed T2-weighted images) that is nonspecific but could represent osteomyelitis in the correct clinical context. Additional bandlike low signal intensity extending longitudinally through the proximal phalanx may represent an old healed fracture. Although there is mild edema-type signal within the head of the proximal phalanx on the fat-suppressed T2-weighted images, the normal fatty marrow signal intensity is relatively preserved on the T1-weighted images, and therefore this more likely represents reactive osteitis than osteomyelitis. Similarly, there is relatively mild increased signal intensity within the distal phalanx of the great toe on the fat-suppressed T2-weighted images, with relative preservation of the normal fatty signal intensity on T1-weighted images, suggesting reactive osteitis rather than osteomyelitis. Deformity of the base of the distal phalanx of the great toe, as seen on radiographs, again may reflect old trauma or sequela of prior infection. I see no fluid signal intensity within the interphalangeal joint or first metatarsophalangeal joint to indicate septic arthritis. The signal intensity of the sesamoid bones is normal. Moderate osteoarthritis affects the first metatarsophalangeal joint. Additional osteoarthritis affects the visualized portions of the midfoot. A small amount of nonenhancing fluid between the first and second metatarsal heads may represent a bursitis.
Soft tissue inflammatory changes as described above, particularly affecting the great toe. Deformity of the proximal phalanx of the great toe and the base of the distal phalanx of the great toe may reflect old trauma or sequela of prior infection. Abnormal signal intensity within the base of the proximal phalanx of the great toe is nonspecific and could represent osteomyelitis in the correct clinical context, although may simply reflect osteoarthritic changes.