Patient History

78-year-old man with a one-month history of a blister on the third left toe with purulent drainage.

Findings

Skeletal/osseous:

Cortical destruction with diffuse confluent osteoedema involving the 3rd toe distal phalanx (mid to proximal portion), middle phalanx (mid to distal portion). Cortical destruction at the distal interphalangeal joint with partial lateral subluxation of the distal phalanx. Proximal interphalangeal joint preserved. Proximal phalanx preserved. No intraosseous abscess/fluid collection or involucrum identified. No sequestrum or cloaca.

Marked hallux valgus deformity with moderate to marked 1st metatarsophalangeal joint osteoarthropathy. Marked hammertoe deformities of the 2nd to 5th toes. Varus deformities of the 2nd to 5th metatarsophalangeal joints.

Moderate to marked lateralization of the sesamoids, due to the hallux valgus deformity. Marked tibial and moderate fibular sesamoid hallux arthrosis. Flattening of the crista and sesamoid grooves.

No micro- or macro-trabecular fracture.

Tendons:

Visualized portions intact.

Ligaments:

Thickened medial and lateral collateral ligaments of the 1st metatarsophalangeal joint.

Plantar plates:

Stretched plantar plates. No macro tear.

Soft tissues:

Soft tissue callus formation/thickening at the plantar aspect of the 5th metatarsal head. Soft tissue thickening/callus formation with fatty atrophy/thinning adjacent to the medial aspect of the 1st metatarsal head.

Extensive soft tissue thickening surrounding the nail bed and dorsal aspect of the distal 3rd toe.

No bulky Morton neuroma. No intermetatarsal bursitis with effusion.

Other:

Partially imaged plantar fascia unremarkable. Diffuse mild fatty infiltration and muscle edema of the intrinsic musculature of the forefoot.

Impressions

  1. Osteomyelitis involving the 3rd toe middle phalanx and proximal segment of the distal phalanx with DIPJ septic arthritis. Possible contiguous extension from an adjacent nailbed infection. Proximal interphalangeal joint preserved.
  2. Marked hallux valgus deformity with lateralized sesamoids. Moderate to marked degenerative arthrosis 1st MTPJ, tibial hallux-sesamoid and moderate fibular hallux-sesamoid arthrosis. 
  3. Incidental 2nd through 5th hammertoe deformities.
  4. Incidental mild diffuse fatty infiltration and muscle edema of the intrinsic forefoot musculature. Assessment for systemic neuropathy recommended.