Advanced osteomyelitis due to open metatarsal fracture

Case contributed by Dr Bálint Botz

Presentation

Known diabetes. Heavy weight dropped on the right forefoot abroad, confirmed first metatarsal fracture which was managed conservatively there (prior documentation unavailable). Presents 20 days after the initial injury. Asymptomatic and weight bearing. Upon presentation marked forefoot swelling, the metatarsal head is visible in the injury. Osteomyelitis?

Patient Data

Age: 50 years
Gender: Male
  • Advanced lytic destruction of the first metatarsal bone and phalanges with associated soft tissue swelling and small locules of gas.
  • Marked periosteal reaction on the lateral aspect of the first metatarsal likely due to suboptimal fracture healing or as secondary consequence of the osteomyelitis. 
  • The head of the first metatarsal is extruding through the soft tissue defect. 
  • Disseminated lytic bone destruction, periostal reaction,  with extrusion of the head of the first metatarsus redemonstrated.
  • Note intraosseous gas in the remnants of the phalanges, indicative of the unusal emphysematous form of osteomyelitis
  • Multiple associated soft tissue collections with locules of gas in line with advanced gangrenous process. 

Case Discussion

The delayed presentation coupled with a lack compliance and symptoms (possibly due to diabetic neuropathy) resulted in a poor outcome, as agressive necrectomy and amputation of the first metatarsal could not be avoided. 

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