Ankle and Foot 47 - Department of Radiology - University of ...

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Figure 47-111. Rapid onset of severe Charcot neuropathic collapse in a diabetic patient. Anteroposterior (A) and oblique (B) radiographs show anatomic alignment along the Lisfranc joint. Anteroposterior (C) and oblique (D) radiographs only 3 months later reveal complete destruction of the Lisfranc joint. A B C D A B Figure 47-112. Radiographic evidence of active osteomyelitis in a 39-year-old. A, Oblique radiograph of the toes reveals subtle erosions in the lateral cortex of the fourth middle phalanx (arrow) and the lateral head of the fourth proximal phalanx (black arrowhead). Incidentally seen is a metallic foreign body (white arrowhead), not an uncommon finding in patients who are insensate because of peripheral neuropathy. B, Same oblique view just 2 months later reveals a new erosion in the medial cortex of the fourth middle phalanx (white arrow). The rapid onset of this erosion is highly suggestive of osteomyelitis. Marginal erosions from noninfectious inflammatory arthropathies such as rheumatoid arthritis, or crystalline arthropathies such as gout, could have a similar appearance but would not be expected to exhibit such rapid changes. Ch047-A05375.indd 2308 9/9/2008 5:36:12 PM
47 Ankle and Foot 2309 47 Figure 47-113. Evolution of involucrum in chronic osteomyelitis in a patient with diabetes. A, Anteroposterior radiograph reveals a somewhat lamellated periosteal reaction around the diaphysis of the fifth metatarsal. B, Six weeks later, the periosteal reaction is thicker and more mature. C, Eleven weeks later, the periosteal reaction has developed the thick, irregular appearance of an involucrum. The underlying metatarsal has become a dead and sclerotic sequestrum. A B C Figure 47-114. Early neuropathic changes in a 66- year-old with a long history of diabetes. Oblique axial T1-weighted (A) and T2-weighted fat-suppressed (B) images show marrow edema throughout the midfoot bones. A B rules out the diagnosis of osteomyelitis. However, the converse is not true. Although the presence of bone marrow edema may be due to infection, the edema may represent a sterile stress response owing to the altered biomechanics of the patient walking on a neuropathic foot that has not yet collapsed. Indeed, marrow edema diffusely involving several of the tarsal bones can indicate neuropathic precollapse (Fig. 47-114), and such patients need to be treated with a prolonged period of non–weight bearing. The diagnosis of osteomyelitis can be presumed when MRI shows not only marrow edema but also abscess in the adjacent soft tissues (Fig. 47-115) or a sinus tract communicating from the infected bone to the skin. 1 IVGd-based contrast is extremely helpful in diagnosing the abscess, which exhibits thick, irregular enhancement peripherally but not centrally (see Fig. 47-115H and K). • Brodie’s Abscess Brodie’s* abscess is a chronic intraosseous abscess resulting from incomplete resolution of acute osteomyelitis and isolation of the infection by surrounding bone. These abscess pockets are typically found in the metaphyses of skeletally immature children, and the usual pathogen is Staphylococcus aureus. However, the organisms tend to be of low virulence, *Sir Benjamin Collins Brodie (1783-1862) was an English physiologist and surgeon who pioneered research into bone and joint disease. His most important work is widely acknowledged to be the 1818 treatise Pathological and Surgical Observations on the Diseases of the Joints, in which he attempts to trace the beginnings of disease in the different tissues that form a joint and to give an exact value to the symptom of pain as evidence of organic disease. This volume led to the adoption by surgeons of more conservative measures in the treatment of diseases of the joints, with consequent reduction in the number of amputations and the saving of many limbs and lives. Ch047-A05375.indd 2309 9/9/2008 5:36:14 PM
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Ankle and Foot 47 - Department of Radiology - University of ...

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