0:00

53 year old with, uh,

0:02

cellulitis and pain of the right toes on this, uh,

0:06

foot MRI. And typically, I'll, I'll hang obviously a,

0:11

a sagittal, a coronal and, and mind you and an axial. But, uh, just be,

0:16

just to be mindful that, uh, um, you know, some,

0:20

some institutions label their coronial, coronal and axials if we're talking to,

0:25

relative to the foot or the body. Um, so I apologize if, um,

0:30

I slip into short axis and, and long axis. Um, but I'll try to use all the,

0:35

the correct orientations just to orient everyone, uh,

0:39

keep everyone oriented and on the same page. But, uh, going, uh,

0:43

just to the, um, findings in this, uh, case here,

0:48

obviously there's a, uh, a altered marrow signal. Okay,

0:53

that's, uh, stir or T two Bright here,

0:57

as well as a corresponding T one marrow replacement, uh,

1:01

involving the first distal phx. So this is, uh, a nice, um,

1:06

uh, uh, classic case of osteomyelitis of the, uh, the great toe,

1:11

um, distal phx. So, as we know, uh, osteomyelitis,

1:16

uh, can be acquired or, or, uh, from two or three different routes,

1:21

right? Uh, so classically with kids,

1:24

it's gonna be more hematogenous in adults, it, it's gonna be more direct,

1:29

um, inoculation or perhaps, uh, perhaps, uh,

1:32

most often from an ulcer or, uh, unfortunately sometimes iatrogenic.

1:37

Okay? Um, most common bug, uh, as hopefully everyone, uh,

1:42

as we can remind ourselves is, is typically gonna be staph. Um, when you start,

1:47

uh, you know, if you're an endemic region, where there,

1:49

where there's TB that's obviously, or fungus,

1:53

that's obviously something to throw on the differential. And then you can get,

1:56

uh, more nuanced, especially with the history. You know, if there's, uh,

2:01

a history of, uh, sickle cell, IV drug use, things like that,

2:04

then you want to think of weirder bugs like e coli and,

2:07

and salmonella respectively, or even, uh, you know, like a Klebsiella,

2:12

what have you. Um, so this is just a nice case of osteomyelitis.

2:17

Um, I often get asked, uh, what do I rely on the most? Uh,

2:21

I like a nice T one, okay? And when I'm imaging the toes,

2:26

I prefer stirs, um, you know, 'cause, uh, chemical fats at, or,

2:30

or just a run the mill of T two fat at, we can get that, uh,

2:33

fat sat failure more distally. So I like to, um, encourage my techs,

2:39

uh, at our institution to run stirs or I'll, I'll try to monitor the case.

2:44

Um, and if the T two fat SATs or, or pd fat SATs, what have you or not,

2:49

uh, turning out optimally, uh, especially more distally,

2:53

then I'll ask the tech to run a just a nice sagittal stir. Um,

2:58

and, you know, to clarify whether that's, uh, true mar edema. Now,

3:03

uh, on top of that, the T one is gonna be the most specific,

3:06

and there have been articles, uh, uh, particularly as of late,

3:10

or if you follow the literature on osteomyelitis, um, uh,

3:14

relatively recent article out of, uh, Penn State Hershey, uh,

3:18

that group showed, um, looked at some interesting things.

3:23

So what do you do when there's, you know, um, T one, um,

3:27

there when there's no T one marrow replacement, okay, to go along with T two,

3:32

uh, or stir edema, right? So, and what they found is,

3:37

and, and,

3:38

and you can double check and I can try to get those articles out to y'all again,

3:42

but, uh, um, osteomyelitis, um, when you have, uh,

3:46

stir the positive stir signal edema, but no T one ME replacement,

3:50

what they found in their cohort was about 60%,

3:54

60 to 65% of those patients actually go on ultimately to get osteomyelitis.

3:59

So when I'm faced with a case where there is no T one marrow replacement to

4:03

corroborate the T two or stir edema,

4:07

then I will raise the possibility that this could be early osteomyelitis,

4:10

making sure that, uh,

4:13

the patient at least gets some sort of antibiotics. Um, because, you know,

4:17

odds are then that, you know,

4:19

those patients will go on to get osteomyelitis and unfortunately toe amputation

4:24

or what have you. Um, anyway, so I, I I want to, uh, I I become more aggressive,

4:29

but that's also, um, also being mindful. Um, I, I,

4:33

I serve, uh, uh, an indigent population. So I, you know,

4:38

we sometimes lose patients because of social issues, uh, to care.

4:42

So that's why I, I tend to be more aggressive, uh, especially in,

4:47

in my patient population because that may be the only chance that, um,

4:52

our, our health, uh, care system may see this patient, unfortunately, uh,

4:56

said such patients, unfortunately. So that's why I tend to come down harder.

5:00

But if there is T one marrow replacement,

5:02

I'll just call it outright osteomyelitis, before I forget,

5:06

there was a couple questions.

5:07

There was some confusion between the terms osteitis

5:12

per titis and osteomyelitis. Okay? So using,

5:17

let's use, uh, just this, uh, uh, ankle, MRI,

5:21

so peri perio osteoperiostitis, right?

5:25

Is just gonna be that inflammation, whether it's non-infectious or infectious,

5:29

right? Um, uh, edema of the periosteum,

5:33

or that is the, the, the outsider, the overlying the cortex, right?

5:38

Osteitis is inflammation of the cor cortex, okay?

5:44

Osteomyelitis, right? Is involvement of the myeloid or the,

5:49

the marrow forming elements. So the intramedullary space is involved, right?

5:55

So, so some

5:56

People had read, um, uh,

5:59

the di or provided the diagnosis of osteo for the first case of

6:04

osteomyelitis. So, um, you know, I just want to encourage you guys,

6:09

when the medullary space is involved,

6:12

you wanna add the term myelitis to Osteitis.

6:16

So make it into osteomyelitis because, um, you know,

6:21

they, that that just means more extensive involvement of the bone. Um, uh,

6:26

but I defer to my infectious disease and,

6:29

and podiatrist and orthopedic colleagues to deal with the antibiotics,

6:33

but they obviously, uh,

6:35

would like to probably know the extent of involvement.

6:39

So just for consistency of terminology, I, I would encourage, um,

6:44

and, and this is my understanding of the current literature,

6:47

osteo involves the cortex,

6:50

osteomyelitis involves the intramedullary space. Okay? So,

6:55

so just some, uh, a clarification for, uh,

6:57

case one that I got some questions on about this week.