A 69-year-old female patient with type 2 diabetes diagnosed at the age of 54 years and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic for an infection of her right second toe. She had background diabetic retinopathy and hypertension. She complained of numbness and a sensation of pins and needles in her feet at night.

On examination, she had findings of severe neuropathy (no feeling of light touch, pain, temperature, vibration or a 5.08 monofilament; Achilles tendon reflexes were absent; the vibration perception threshold was >50 V in both feet). Peripheral pulses were weak and the ankle brachial index was 0.7. Dry skin and nail dystrophies were present. A superficial ulcer with a sloughy base was seen on the dorsum of her right second toe which was red, swollen and painful, having a sausage-like appearance (Figure 8.18). She did not mention any trauma, but inspection of her shoes revealed a prominent seam inside the toe box of her right shoe.

The sausage-like appearance of a toe usually denotes osteomyelitis. Bone infection was confirmed on X-ray, showing osteolysis of the first and second phalanges. Staphylococcus aureus and Kleb-siella pneumoniae were cultured from the base of the ulcer. The patient was treated with cotrimoxazole and clindamycin for 2 months. She was also referred to the Vascular Surgery Department for a percutaneous transluminal angioplasty of her right popliteal artery. After 2 months the ulcer was still active and the patient had local extension of osteomyelitis despite the restoration of the circulation in the periphery. She eventually had her second

2nd Toe Sloughy Ulcer
Figure 8.18 Sausage-like toe deformity usually denotes underlying osteomyelitis

ray amputated. A bone culture revealed the presence of Staphylococcus aureus. She continued with cotrimoxazole for two more weeks.

Keywords: Osteomyelitis; painful-painless feet

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