Tendon Involvement in Pedal Infection: MR Analysis of Frequency, Distribution, and Spread of Infection
Hans Peter Ledermann1,2,
William B. Morrison2,
Mark E. Schweitzer2 and
Steven M. Raikin3
1 Radiologisches Institut, Universitätsspital Basel, Petersgraben 4, 4031
Basel, Switzerland.
2 Department of Radiology, Thomas Jefferson University Hospital, 111 S. 11th
St., No. 3390, Gibbon, Philadelphia, PA 19107.
3 Department of Othopedic Surgery, Rothman Institute, Thomas Jefferson
University Hospital, 925 Chestnut St., Philadelphia, PA 19107.
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Fig. 1A. —54-year-old man with diabetes mellitus who presented with
chronic nonhealing wound of great toe after resection of interphalangeal
joint. Coronal T1-weighted fat-suppressed contrast-enhanced fast multiplanar
spoiled gradient-recalled (FMPSPGR) MR image (TR/TE, 250/2.1; flip angle,
90°) shows large defect (arrow) in great toe filled with gauze.
Note small ulcer (between arrowheads) at medial aspect of second toe
with interruption of skin line.
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Fig. 1B. —54-year-old man with diabetes mellitus who presented with
chronic nonhealing wound of great toe after resection of interphalangeal
joint. Coronal T2-weighted fast spin-echo short tau inversion recovery MR
image (5200/62; inversion time, 150 msec) reveals rim of fluid intensity
signal around flexor hallucis longus tendon (black arrow) and
extensor hallucis tendon (arrowhead). Note hyperintense signal in
stump of proximal phalanx (white arrow), indicating
osteomyelitis.
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Fig. 1C. —54-year-old man with diabetes mellitus who presented with
chronic nonhealing wound of great toe after resection of interphalangeal
joint. Coronal T1-weighted fat-suppressed contrast-enhanced FMPSPGR MR image
(250/2.1; flip angle, 90°) reveals patchy enhancement of flexor hallucis
longus tendon (black arrow) and extensor hallucis longus tendon
(arrowhead) with rim enhancement. Also note diffuse contrast
enhancement of first toe, representing cellulitis. Contrast enhancement of
stump of proximal first phalanx (white arrow) confirms
osteomyelitis.
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Fig. 2A. —49-year-old man with diabetes mellitus who presented with
chronic heel ulceration and extensive soft-tissue infection. Coronal
T1-weighted spin-echo MR image (TR/TE, 400/15) reveals extensive swelling of
soft tissues with lateral displacement of peroneal tendons (white
arrow). Note round hypointense collections (black arrows)
adjacent to peroneal tendons.
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Fig. 2B. —49-year-old man with diabetes mellitus who presented with
chronic heel ulceration and extensive soft-tissue infection. Coronal
T2-weighted fat-suppressed fast spin-echo MR image (5800/75) reveals fluid
collection (black arrows) around peroneal tendons (white
arrow).
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Fig. 2C. —49-year-old man with diabetes mellitus who presented with
chronic heel ulceration and extensive soft-tissue infection. Sagittal
T2-weighted fat-suppressed fast spin-echo MR image (5800/75) of lateral
hindfoot reveals round collection (arrow) adjacent to peroneal
tendons and extension of fluid signal (arrowheads) proximally and
distally along course of peroneal tendons.
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Fig. 2D. —49-year-old man with diabetes mellitus who presented with
chronic heel ulceration and extensive soft-tissue infection. Coronal
T1-weighted fat-suppressed contrast-enhanced fast multiplanar spoiled
gradient-recalled MR image (250/2.1; flip angle, 90°) documents peripheral
ring enhancement of peritendinous collections (black arrows) and
peroneal tendon sheath (white arrow). These findings indicate septic
tenosynovitis with small peritendinous abscesses is present.
Débridement proved presence of septic tenosynovitis.
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Fig. 3A. —27-year-old man with paraplegia who presented with large
chronic heel ulcer and clinically suspected calcaneal osteomyelitis. Sagittal
T1-weighted spin-echo MR image (TR/TE, 470/12) reveals large heel ulcer
(between white arrowheads) and extensive hypointense marrow signal
alteration (black arrowheads) in exposed calcaneal tuber. Note
abnormal signal elevation (arrow) of distal Achilles tendon at border
of large ulcer.
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Fig. 3B. —27-year-old man with paraplegia who presented with large
chronic heel ulcer and clinically suspected calcaneal osteomyelitis. Sagittal
T2-weighted fat-suppressed fast spin-echo MR image (5800/75) documents
extensive marrow hyperintensity (arrowheads) in calcaneal tuber,
which indicates osteomyelitis. Note abnormal hyperintense signal
(arrow) of distal Achilles tendon.
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Fig. 3C. —27-year-old man with paraplegia who presented with large
chronic heel ulcer and clinically suspected calcaneal osteomyelitis. Sagittal
T1-weighted fat-suppressed contrast-enhanced fast multiplanar spoiled
gradient-recalled MR image (250/2.1; flip angle, 90°) reveals extensive
contrast enhancement (arrowheads) in calcaneus, confirming
osteomyelitis. Marked contrast enhancement (arrow) in distal Achilles
tendon is compatible with focal infection of Achilles tendon. Contrast
enhancement in navicular bone and talus may reflect neuropathic arthropathy in
Chopart's joint. Focal contrast enhancement in distal tibia around pin tract
from previously removed distraction device is also visible.
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Fig. 4A. —63-year-old man with diabetes mellitus who presented with
chronic ulceration of first web space. Axial T2-weighted fat-suppressed fast
spin-echo MR image (TR/TE, 5400/85) shows subcutaneous edema (arrow)
at plantar aspect of first web space adjacent to interdigital ulceration. Note
extension of hyperintense signal around second flexor tendon
(arrowheads) into central plantar compartment.
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Fig. 4B. —63-year-old man with diabetes mellitus who presented with
chronic ulceration of first web space. Sagittal T2-weighted fat-suppressed
fast spin-echo MR image (5400/85) reveals two hyperintense collections. One
collection (arrowheads) is located subcutaneously at plantar aspect
of forefoot, and other collection (arrow) is located in central
plantar compartment.
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Fig. 4C. —63-year-old man with diabetes mellitus who presented with
chronic ulceration of first web space. Coronal T2-weighted fat-suppressed MR
image confirms that proximal fluid collection (arrow) is located in
central plantar compartment.
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Fig. 4D. —63-year-old man with diabetes mellitus who presented with
chronic ulceration of first web space. Contrast-enhanced fat-suppressed
T1-weighted fast multiplanar spoiled gradient-recalled image (250/2.1; flip
angle, 90°) reveals thin rim of contrast enhancement
(arrowheads). This finding confirms presence of central plantar
compartment abscess.
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