Presentation
2 year history of toe swelling with previous P2 amputation.
Patient Data
On radiographs of the left pelvic limb, there is lysis of the second metatarsal bone with only a proximal remnant. The third digit, including P1-2 and the distal metatarsal bone, are also lytic. The regions surrounding the distal interphalangeal joint of the 5th phalanx are also lytic. The 4th phalanx appears intact. There are small fragments of soft tissue in the region of the lytic metatarsal bones. The soft tissues surrounding this region are thickened, and there is smooth periosteal reaction and sclerosis of the third and fourth metatarsal bones.
Severe multifocal aggressive bone lesions with osteolysis in the distal left pelvic metatarsal and phalangeal regions. This is most likely due to osteomyelitis, however a soft tissue neoplasm invading bone cannot be completely ruled out.
Case Discussion
The digits were amputated and osteomyelitis was found in P3, with resorption and fibrous replacement of bone in P5. No organisms were isolated. The chronic nature of the osteomyelitis has resulted in the tapered appearance of the metatarsal bone and fairly smooth periosteal reaction.
Radiographs can be insensitive for osteomyelitis as the only sign may be soft tissue swelling in the early phases of disease. Later, changes to the bone include cortical thinning or lysis, loss of trabecular pattern, periosteal reaction, and lucency surrounding any implants present. Sequestra may form in affected bones.
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