RADIOLOGICAL ASSESSMENT

OF DIABETIC FOOT
Diabetic Foot Patients :

1. Peripheral Vascular Disease.

2. Infection cellulitis, soft tissue abscess, osteomyelitis or

septic Arthritis

3. Neuropathic (Charcots) Arthropathy .

IBMS 2008
VASCULAR CALCIFICATIONS & OSTEOPAENIA
 INFECTION
90% of cases
contiguous spread through the skin
Ulcers / FB / Bites

Haematogenous spread

Radiopaedia 2011
 Pressure points :
Forefoot (MTP and IP joints )
Hindfoot calcaneum
Plain xray:
Classic Triads OM
Lucencies
Periosteal reaction
Bony destruction

xrays2000
DRAWBACKS:

Poor sensitivity (22-75%)- om changes are delayed for 10-21 days

following infection.

Specificity is 75-83% - neuroarthropathy , previous fractures,

osteonecrosis, tumour, non neoplastic disease

30-50% loss of bone density - before OM visible.

OM :
periosteal reaction
Proximal phalanx
Soft tissue swelling

xrays2000
 OM
Focal loss of
trabecular pattern
Soft tissue swelling

MGH RAD DEPT. 2006

 Secondary
signs:
gas in soft
tissues
cortical
erosion

MGH RAD DEPT. 2006

 gas in soft tissues
ulcers, skin lacerations, FB inoculation
E Coli, S Bacteroides, Clostridium
Perfrigerans

Medscape 2011
Chronic heel ulcer & OM :
Skin induration, cortical
disruption & marrow
signal change

BRJ 2007
Subacute om : penumbra sign
An intraosseous abscess
BRJ 2007
OM & Abscesses : MTP Joints
BRJ 2007
OM and sinus tract MT Head
BRJ 2007
Cellulitis, tenosynovitis,
Osteomyelitis (multifocal)

BRJ 2007
 NEUROPATHIC ARTHROPATHY (NA)
DM with PVD & PN

Acute onset : Radiographically - almost normal

Chronic stage : density , distension, destruction , debris ,

deformity & dislocation.

RADIOLOGY ASSIISTANT 2011

Locations:
Midtarsal, intertarsaL & Lisfranc TMT joints : 60%
MTP joints : 30%
IP jts : uncommon
Debris & Density
Midtarsal neuropathic Joint

Medscape 2011
Medscape 2011
 CHRONIC NEUROPATHIC JOINTS

TMT and intertarsal jts

Pencil shape taperings

phalanges and heads of
MT

Medscape 2007
MTP & tarsometatarsal Jts : soft-tissue swelling,
fragmentation, sclerosis, and periostitis.
Medscape 2007
Acute NA :
bone marrow oedema - midfoot .
Subarticular bone enhancement : articular disease.
subcutaneous tissues : minimal involvement
No ulcer or other signs of infection.
RADIOLOGY ASISSTANT 2011
NA without OM :
Rocker-bottom with Ds
chronic healing ulcer.
Normal marrow

BRJ 2007
INFECTION IN NEUROPATHIC JOINT

Medscape 2011
NA with OM: Rocker-bottom with Ds, ulcer & enhancing
marrow in cuboid .
Radiology Assistant 2011
NA with OM :

midtarsal joints,
diffuse marrow,
cellulitis,
devitalized bony
fragments.

BRJ 2007
 Neuropathic Arthropathy VS OM
Predominantly joint Predominantly bone
unless septic arthritis
Intertarsal & midtarsal, Pressure points hind &
tarsometatarsal , MTP fore foot (calcaneum,
joints. MTP & IP joints)
Lack of soft tissue Gas or FB
component. Associated cellutis,
abscess or tenosynovitis.
 NUCLEAR MEDICINE
99mTC MDP 3 phase bone scintigraphy is sensitive (85%) but
not specific neuropathic jt, fractures, chronic cellulitis .

Leucocytes labelled scintigraphy may be useful in diagnosing

and follow up cases & specificity 80 - 90%.

Combined leucocytes labelled & marrow

scintigraphy may increase diagnostic
rate of infected neuropathic joint.
 FRACTURES

Calcaneal insufficiency
Avulsion fracture:
posterior 1/3 calcaneum.
osteoporosis &
neuropathic change
.

RADIOGRAPHICS 1999
ALL IN ONE

RADIOPAEDIA 2011
RADIOPAEDIA 2011
 CONCLUSION
Common radiological diagnosis in pts with
diabetic foot are infections and Neuropathic
Arthropathy .
Plain xrays is easiest , cheapest but fair
sensitivity and specificity.
MRI is excellent for detecting infection,
osteomyelitis and associated complications.
Difficult to differentiate OM vs acute NA or
presence of OM in the NA .
 THANK YOU

MAIZATULJAMNY MAHMOOD
MBBS MRAD
GHKL