Practice Rational Imaging

Investigating suspected bone infection in the diabetic foot

BMJ 2009; 339 doi: (Published 04 December 2009) Cite this as: BMJ 2009;339:b4690
  1. James Teh, consultant radiologist 1,
  2. Tony Berendt, consultant physician 2,
  3. Benjamin A Lipsky, professor of medicine3
  1. 1Radiology Department, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD
  2. 2Bone Infection Unit, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD
  3. 3VA Puget Sound Health Care System and University of Washington, Seattle, WA 98416, USA
  1. Correspondence to: J Teh james.teh{at}

    Accurate and early diagnosis of this condition is key to successful management. This article guides you through the diagnostic options

    Learning points

    • Diabetic foot osteomyelitis is invariably accompanied by foot ulceration

    • Plain radiography should be the first imaging test used but may not show changes for up to two weeks

    • Magnetic resonance imaging is the most accurate imaging modality

    • Nuclear medicine scans play only a modest role in the diagnosis

    • Bone biopsy is the criterion standard for the diagnosis of osteomyelitis but is not needed in every case

    The patient

    A 58 year old man with long standing type 2 diabetes presented with a non-healing ulcer on the side of the right great toe, with associated spreading cellulitis. Laboratory tests showed a white blood cell count of 11.3×109/l (normal range 3.2-9.8), a neutrophil count of 5×109/l (3-5.8), and an erythrocyte sedimentation rate of 45 mm/h (normal <15). He had a history of peripheral neuropathy, peripheral vascular disease, and renal failure caused by diabetic nephropathy. He was referred for imaging of suspected osteomyelitis.

    Osteomyelitis of the foot is a common and challenging problem in patients with diabetes.1 Around 25% of patients with diabetes will develop a foot ulcer, usually at areas of pressure, such as the heel or metatarsal heads.2 Osteomyelitis is almost always caused by contiguous spread of infection from overlying foot ulceration and complicates up to 20% of ulcers.3

    The two major difficulties in diagnosing diabetic foot osteomyelitis are that imaging tests can be insensitive to early disease and that bony changes related to neuroarthropathy (Charcot’s foot) can mimic infective change. Accurate and early diagnosis of this condition is the key to successful management, which may include prolonged treatment with antibiotics or surgical resection.4 5

    Clinicians should suspect osteomyelitis when a foot ulcer is deep, …

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