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Is Soft-Tissue Inflammation in Pedal Infection Contained by Fascial Planes? MR Analysis of Compartmental Involvement in 115 Feet

Hans Peter Ledermann1,2, William B. Morrison1 and Mark E. Schweitzer1

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



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  		Fig. 1A. —Compartmental anatomy of forefoot and midfoot. D = dorsal compartment, L = lateral compartment, C = central compartment, M = medial compartment, I = interosseous compartment. Schematic anatomic drawing shows forefoot compartments.

 


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  		Fig. 1B. —Compartmental anatomy of forefoot and midfoot. D = dorsal compartment, L = lateral compartment, C = central compartment, M = medial compartment, I = interosseous compartment. Schematic anatomic drawing shows midfoot compartments.

 


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  		Fig. 2C. —40-year-old woman with diabetes mellitus whose soft-tissue inflammation has spread from medial compartment infection into central, interosseous, and dorsal compartments. Coronal T1-weighted spin-echo MR image (500/17) at more proximal level than A reveals fat signal intensity loss originating from medial compartment and spreading into central compartment (small black arrows) and further dorsally into interosseous compartment (large black arrow) and dorsal compartment (white arrow).

 


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  		Fig. 2D. —40-year-old woman with diabetes mellitus whose soft-tissue inflammation has spread from medial compartment infection into central, interosseous, and dorsal compartments. Coronal contrast enhanced fat-suppressed T1-weighted spin-echo MR image (500/17) at same level as C confirms spread of soft-tissue inflammation from medial into central compartment (small black arrows), interosseous compartment (large black arrow), and dorsal compartment (white arrow).

 


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  		Fig. 3A. —66-year-old man with diabetes mellitus in whom gas-forming infection in lateral forefoot has spread from lateral compartment across forefoot into three other compartments. Sagittal T1-weighted spin-echo MR image (TR/TE, 500/8) of right lateral forefoot with ulcer (arrow) slightly proximal to fifth metatarsophalangeal joint and hypointense air collection in dorsal compartment (arrowhead).

 


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  		Fig. 3B. —66-year-old man with diabetes mellitus in whom gas-forming infection in lateral forefoot has spread from lateral compartment across forefoot into three other compartments. Coronal T2-weighted fat-suppressed fast spin-echo MR image (3,717/88) reveals spread of gas and surrounding edema into central compartment (black arrow). From there, gas bubbles and edema extend dorsally into interosseous compartment (white arrow) between shaft of metatarsal bones three and four. Further gas inclusions are seen in dorsal compartment (arrowhead).

 


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  		Fig. 3C. —66-year-old man with diabetes mellitus in whom gas-forming infection in lateral forefoot has spread from lateral compartment across forefoot into three other compartments. Coronal T1-weighted contrast enhanced fast multiplane spoiled gradient recalled MR image (250/2.1; flip angle, 90°) more proximally reveals extensive contiguous gas inclusions in central compartment (black arrow), interosseous compartment (white arrow), and dorsal compartment (arrowhead).

 


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  		Fig. 2A. —40-year-old woman with diabetes mellitus whose soft-tissue inflammation has spread from medial compartment infection into central, interosseous, and dorsal compartments. Coronal T1-weighted spin-echo MR image (TR/TE, 500/17) of forefoot with large ulcer located medially (between arrowheads). At this level, loss of fat signal intensity is restricted to medial compartment (black arrow) and to dorsal compartment (white arrow).

 


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  		Fig. 2B. —40-year-old woman with diabetes mellitus whose soft-tissue inflammation has spread from medial compartment infection into central, interosseous, and dorsal compartments. Coronal T1-weighted contrast enhanced fat-suppressed spin-echo MR image (633/14) reveals plantar abscess in medial compartment (arrowheads) with direct communication to ulcer. Rim enhancement (arrows) around first metatarsophalangeal joint indicates septic arthritis.

 


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  		Fig. 4A. —64-year-old man with diabetes mellitus and extensive infection of heel without evidence of inflammatory spread into neighboring compartments. Sagittal T1-weighted spin-echo MR image (TR/TE, 433/8) of hindfoot with large skin ulceration (arrow) and overlying dressing (arrowheads).

 


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  		Fig. 4B. —64-year-old man with diabetes mellitus and extensive infection of heel without evidence of inflammatory spread into neighboring compartments. Sagittal T2-weighted fast spin-echo short inversion time recovery MR image (4833/45, inversion time, 150 msec) reveals erosion of the calcaneal tubercle (arrow) and hyperintense signal (arrowheads) in the calcaneus, indicative of osteomyelitis.

 


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  		Fig. 4C. —64-year-old man with diabetes mellitus and extensive infection of heel without evidence of inflammatory spread into neighboring compartments. Sagittal T1-weighted contrast-enhanced fast multiplane spoiled gradient-recalled MR image (250/2.1; flip angle, 90°) confirming calcaneal osteomyelitis and erosion of calcaneal tubercle (arrow). Soft-tissue contrast enhancement is confined to hindfoot without evidence of inflammatory spread.

 


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  		Fig. 4D. —64-year-old man with diabetes mellitus and extensive infection of heel without evidence of inflammatory spread into neighboring compartments. Axial T1-weighted contrast enhanced fat-suppressed spin-echo MR image (423/9) shows large ulceration (arrow) of lateral heel with calcaneal osteomyelitis (arrowheads). No evidence of distal extension of soft-tissue inflammation into midfoot can be seen.

 

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