Acute pyogenic osteomyelitis of the metatarsal

Case contributed by Charlie Chia-Tsong Hsu
Diagnosis certain


Stepped on a thorn. Penetrating injury to plantar surface of left foot.

Patient Data

Age: 40 years
Gender: Male

Initial radiograph 3 days after the inciting event is unremarkable. 

repeated at 14 days


Erosion of the intramedullary trabeculae and cortical destruction of the head of the 4th metatarsal. 

Technetium 99m HDP (bone scan)

Nuclear medicine

Blood flow and blood pool images show increased radiotracer distribution in the left distal foot, likely localizing to the distal aspect of the 4th metatarsal.

Case Discussion

Acute pyogenic osteomyelitis within the first 48 hours may show subtle soft tissue swelling, loss of fat planes or air within the tissue track from the penetrating injury but most often radiograph is entirely normal. At 1 week the earliest radiograph feature is intramedullary trabeculae destruction. This is followed by enosteal scalloping, cortical destruction and periostitis which is only apparent after 2 weeks. Chronic osteomyelitis is typified by periosteal new bone formation, sequestrum/involucrum which maybe seen from 6 week onwards. 

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