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Nonenhancing Tissue on MR Imaging of Pedal Infection

Characterization of Necrotic Tissue and Associated Limitations for Diagnosis of Osteomyelitis and Abscess

¹ Department of Radiology, Thomas Jefferson University Hospital, 111 S. 11th St., Rm. 3390 Gibbon, Philadelphia, PA 19107.
² Present address: FMH Diagnostische Radiologie, Oberer Batterieweg 57, 4059 Basel, Switzerland.

View larger version (96K): [in a new window]   Fig. 1A. —Region-of-interest measurements of relative signal increase on contrast-enhanced versus unenhanced MR images in 60-year-old man with gangrene of distal lateral forefoot. Coronal (transverse to long axis of foot) unenhanced fat-suppressed fast multiplanar spoiled gradient-recalled echo (FMPSPGR) image (TR/TE, 250/2.1; flip angle, 90°) of left forefoot indicates signal intensity measurements dorsally and on lateral forefoot. Note skin ulcer dorsally to second metatarsal shaft.

View larger version (109K): [in a new window]   Fig. 1B. —Region-of-interest measurements of relative signal increase on contrast-enhanced versus unenhanced MR images in 60-year-old man with gangrene of distal lateral forefoot. Contrast-enhanced, fat-suppressed FMPSPGR image (250/2.1; flip angle, 90°) indicates signal increase of 60% dorsally in inflamed subcutis. However, on lateral plantar forefoot, no enhancement (4%) is measured, which corresponds to clinically established gangrene.

View larger version (111K): [in a new window]   Fig. 1C. —Region-of-interest measurements of relative signal increase on contrast-enhanced versus unenhanced MR images in 60-year-old man with gangrene of distal lateral forefoot. Sagittal contrast-enhanced, fat-suppressed FMPSPGR image (250/2.1; flip angle, 90°) of forefoot reveals sharp demarcation between nonenhancing and enhancing tissue (arrowheads). Septic tenosynovitis of flexor tendons is also seen (arrow). Necrosis of lateral forefoot was confirmed at surgery.

View larger version (84K): [in a new window]   Fig. 2C. —Large necrotic plantar ulcer in 51-year-old diabetic man. T1-weighted contrast-enhanced fat-suppressed fast multiplanar spoiled gradient-recalled echo MR image (250/2.1; flip angle, 90°) reveals nonenhancing tissue (small arrows) around base of ulcer extending through interosseous space (arrowhead) to dorsum of foot (large arrow). Local débridement on same day as MR imaging proved presence of necrotic soft tissue in area of nonenhancement.

View larger version (101K): [in a new window]   Fig. 3D. —Pathologically proven osteomyelitis of fifth proximal phalanx in 60-year-old diabetic man with gangrene of fifth toe and distal lateral forefoot. Contrast-enhanced, fat-suppressed FMPSPGR MR image (250/2.1; flip angle, 90°) reveals nonenhancing tissue at lateral forefoot (arrows) that extends from ulcer around fifth proximal phalanx. No abnormal signal increase is seen in marrow of proximal phalanx. After MR imaging, partial fifth ray amputation was performed, with débridement of all necrotic tissue and resection of fifth metatarsal head.

View larger version (101K): [in a new window]   Fig. 4C. —55-year-old diabetic woman with necrosis of first and second toes and surgically confirmed abscess below first metatarsal head. Contrast-enhanced, fat-suppressed fast multiplanar spoiled gradient-recalled echo (FMPSPGR) MR image (250/2.1; flip angle, 90°) reveals large area of nonenhancement around first metatarsal head, with distinct border (arrow) caused by adjacent contrast enhancement. On dorsum of foot, nonenhancing tissue extends over second metatarsal shaft (arrowhead), corresponding to clinically observed extension of gangrene. Typical ring enhancement indicating abscess is absent.

View larger version (99K): [in a new window]   Fig. 4D. —55-year-old diabetic woman with necrosis of first and second toes and surgically confirmed abscess below first metatarsal head. Axial contrast-enhanced, fat-suppressed FMPSPGR MR image (250/2.1; flip angle, 90°) shows extent of necrotic tissue proximal to metatarsophalangeal joint (arrow).

View larger version (104K): [in a new window]   Fig. 2A. —Large necrotic plantar ulcer in 51-year-old diabetic man. T1-weighted coronal (transverse to long axis of foot) MR image (TR/TE, 400/15) of left forefoot reveals large plantar ulcer (between arrowheads) below third and fourth metatarsophalangeal joints.

View larger version (97K): [in a new window]   Fig. 2B. —Large necrotic plantar ulcer in 51-year-old diabetic man. T2-weighted fat-suppressed MR image (5800/75) reveals mixed hyperintense signal around base of ulcer that extends in triangular shape (arrowheads) to dorsum of foot.

View larger version (101K): [in a new window]   Fig. 3A. —Pathologically proven osteomyelitis of fifth proximal phalanx in 60-year-old diabetic man with gangrene of fifth toe and distal lateral forefoot. Coronal (transverse to long axis of foot) T1-weighted unenhanced MR image (TR/TE, 700/9) of forefoot shows patchy marrow signal in fifth proximal phalanx (long arrow). Ulcer on lateral forefoot is seen as interruption of skin surface (arrowhead). Note small gas inclusions extending from ulcer to lateral aspect of proximal phalanx (short arrows).

View larger version (109K): [in a new window]   Fig. 3B. —Pathologically proven osteomyelitis of fifth proximal phalanx in 60-year-old diabetic man with gangrene of fifth toe and distal lateral forefoot. T2-weighted fat-suppressed MR image (5000/80) reveals hyperintense linear signal along sinus tract that extends from base of ulcer (arrowhead) to metatarsophalangeal joint. Note normal marrow signal at base of fifth proximal phalanx (arrow).

View larger version (112K): [in a new window]   Fig. 3C. —Pathologically proven osteomyelitis of fifth proximal phalanx in 60-year-old diabetic man with gangrene of fifth toe and distal lateral forefoot. Unenhanced fat-suppressed fast multiplanar spoiled gradient-recalled echo (FMPSPGR) MR image (250/2.1; flip angle, 90°) shows linear gas inclusions (arrows) better than A and B because of accentuation of magnetic susceptibility artifact.

View larger version (110K): [in a new window]   Fig. 4A. —55-year-old diabetic woman with necrosis of first and second toes and surgically confirmed abscess below first metatarsal head. Coronal (transverse to long axis of foot) T1-weighted MR image (TR/TE, 433/9) of forefoot shows shallow ulcer (arrow) below first metatarsal head. Note focal loss of fat signal in adjacent soft tissues, with hypointense gas inclusions.

View larger version (108K): [in a new window]   Fig. 4B. —55-year-old diabetic woman with necrosis of first and second toes and surgically confirmed abscess below first metatarsal head. T2-weighted fat-suppressed MR image (5400/85) shows small sinus tract (arrow) with hyperintense signal and mixed signal below first metatarsal head, but no definite evidence of abscess.

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