A 76-year-old woman with type 2 diabetes of 10 years' duration was referred to the diabetic foot clinic by casualty. She had an erythematous right 2nd toe with fusiform swelling (sausage toe) and a sloughy ulcer with a draining sinus which probed to bone (Fig. 5.21). Cellulitis extended onto the dorsum of the foot. She had been aware of redness and swelling of the toe for 3 days and the foot had begun to throb over the previous 24 h.
Pedal pulses were absent. She was sent for X-ray (unremarkable), and for vascular assessment which showed monophasic pulsatile waveforms and elevated indices due to arterial calcification. A deep swab was sent for culture and grew Staphylococcus aureus. The ulcer was debrided and dressed with a foam dressing. Quadruple antibiotics were prescribed initially: oral amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ciprofloxacin 500 mg bd; and then narrowed down to fucidin 500 mg tds and flucloxacillin 500 mg qds. Although repeat X-ray after 2 weeks showed lucency of the terminal phalanx compatible with osteomyelitis, the ulcer healed
in 3 weeks. The fusiform swelling remained but the erythema resolved after 3 months.
' Fusiform swelling (sausage toe) and erythema are frequently associated with osteomyelitis and X-rays are needed to confirm the extent of the infection in the bone and monitor progress
• Erythema may take several weeks to settle if infection was severe
• 'Sausage toe' may resolve with antibiotics: surgery is not always necessary for osteomyelitis
• In some centres osteomyelitis is treated by definitive bone resection followed by 4-6 weeks of parenteral or equivalent therapy.
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