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MRI of the diabetic foot: differentiation of infection from neuropathic change

Nuffield Orthopaedic Centre NHS Trust, Windmill Road, Headington, Oxford OX3 7LD, UK

View larger version (62K): [in this window] [in a new window]   Figure 1. (a) Chronic neuroarthropathy. Sagittal T1 weighted image demonstrating a "Rocker-bottom" appearance of the foot in a patient with diabetic neuroarthropathy. There is induration of the subcutaneous tissues at the site of a chronic healing ulcer (arrowheads). There is midfoot joint disruption and disorganization (arrow). (b) Sagittal short tau inversion recovery (STIR) image demonstrating preservation of the marrow signal despite the joint disorganization indicating a chronic neuroarthopathy.

View larger version (63K): [in this window] [in a new window]   Figure 2. (a) Abscess and osteomyelitis. Axial T1 weighted image demonstrating low signal in the first metatarsal head (arrow) indicating osteomyelitis. (b) Axial T1 weighted image following intravenous gadolinium. There is rim enhancement of a collection adjacent to the first metatarsal head (arrows).

View larger version (55K): [in this window] [in a new window]   Figure 3. (a) Haematogenously acquired tuberculous osteomyelitis and arthritis with devitalized bony fragment. Sagittal short tau inversion recovery (STIR) sequence demonstrating diffuse midfoot joint infection with bone marrow oedema and synovitis. (b) Sagittal T1 weighted image following intravenous gadolinium demonstrates a non-enhancing bony fragment (arrow) indicating devitalization. There is diffuse marrow and synovial enhancement in the midfoot.

View larger version (100K): [in this window] [in a new window]   Figure 4. (a) The "penumbra sign" in subacute osteomyelitis. Coronal T1 weighted image of the hindoot demonstrating an intermediate signal rim (arrow) around a central area of lower signal intensity indicating an intra-osseous abscess in the talus. (b) Coronal short tau inversion recovery (STIR) image demonstrating a fluid signal collection in the talus consistent with an abscess.

View larger version (53K): [in this window] [in a new window]   Figure 5. (a) Neuropathic arthropathy with proven infection. Sagittal T1 weighted image demonstrating midfoot disorganization with talonavicular dislocation. There is loss of the normal fatty marrow signal, with very low signal foci (arrows) seen, indicating devitalized bony fragments. (b) Sagittal short tau inversion recovery (STIR) image demonstrating extensive bone marrow oedema and adjacent cellulitis.

View larger version (55K): [in this window] [in a new window]   Figure 6. (a) Diabetic insufficiency fracture of the calcaneus. Sagittal T1 weighted image demonstrating an insufficiency fracture of the calcaneus in a diabetic patient. (b) Sagittal short tau inversion recovery (STIR) image demonstrating high signal in the calcaneus indicating stress change.

View larger version (112K): [in this window] [in a new window]   Figure 7. Open heel ulcer. SagittalT1 weighted image demonstrating a typical heel ulcer with a defect extending into the subcutaneous tissues with a slightly raised mound of tissue adjacent to the defect (arrows). There is evidence of cortical involvement in the calcaneus indicating osteomyelitis.

View larger version (74K): [in this window] [in a new window]   Figure 8. (a) Chronic heel ulcer with osteomyelitis. Sagittal T1 weighted image demonstrating induration and flattening of the subcutaneous tissues down to the calcaneus. There is cortical disruption with marrow signal change. (b) Sagittal short tau inversion recovery (STIR) sequence demonstrating relative low signal at the ulcer site indicating chronic fibrosis. There is marrow oedema indicating osteomyelitis.

View larger version (87K): [in this window] [in a new window]   Figure 9. Sinus tract with"tram track" pattern. Coronal T1 fat-saturated image following intravenous gadolinium demonstrating an enhancing deep sinus tract (arrow) extending down to the second metatarsal head. There is abnormal signal in the underlying bone marrow indicating osteomyelitis.

View larger version (62K): [in this window] [in a new window]   Figure 10. (a) Cellulitis and midfoot haematogenous osteomyelitis. Sagittal T1 weighted image demonstrating extensive cellulitis of the mid and forefoot with loss of the normal subcutaneous fat signal (arrowheads). (b) Sagittal short tau inversion recovery (STIR) image demonstrating extensive cellulitis (arrowheads) in a patient with osteomyelitis affecting the mid and hindfoot (arrows).

View larger version (68K): [in this window] [in a new window]   Figure 11. (a) Acute neuroarthropathy with soft tissue oedema. Sagittal T1 weighted image demonstrating loss of the normal fatty marrow signal in the midfoot and loss of the normal signal from the subcutaneous tissues indicating oedema. (b) Sagittal short tau inversion recovery (STIR) image demonstrating bone marrow oedema and soft tissue oedema in the midfoot. The appearances may mimic infection both clinically and on imaging.

View larger version (68K): [in this window] [in a new window]   Figure 12. (a) Septic tenosynovitis. Sagittal short tau inversion recovery (STIR) image demonstrating a rim of high signal (arrows) enveloping the extensor hallucis longus (EHL) tendon indicating septic tenosynovitis. The tendon itself returns normal low signal. Note the presence of septic arthritis of the first metatarso-phalangeal joint. (b) Coronal T2 fat-saturated image demonstrating septic tenosynovitis of the EHL tendon.

View larger version (54K): [in this window] [in a new window]   Figure 13. (a) Abscess arising from joint. Sagittal T1 weighted image demonstrating a rounded low signal mass (arrows) which appears to communicate with the first metatarso-phalangeal joint. (b) Sagittal short tau inversion recovery (STIR) image demonstrating a round fluid signal collection overlying the first metatarsophalangeal joint. There is periarticular oedema in the first metatarsal head indicating septic arthritis.