Osteomyelitis Development with Nondisplaced Intra-articular Fractures of the Proximal Phalanx Great Toe

Risk Factors and Pathophysiology

Intra-articular fractures are particularly concerning as they can allow bacteria to access the joint space, which lacks a protective basement membrane, resulting in bacteremia in approximately 70% of cases 1
The presence of a sinus tract or ulcer extending to the bone substantially increases the risk of osteomyelitis 3, 2

MRI is the recommended imaging modality after initial radiographs when osteomyelitis is suspected, as it offers superior accuracy and can effectively rule out infection when negative 1, 4
Negative MRI, defined as maintenance of intramedullary fat signal intensity and integrity of cortical signal intensity, effectively rules out osteomyelitis 1
Laboratory markers such as elevated inflammatory markers combined with clinical findings help differentiate osteomyelitis from other conditions 3, 5
The probe-to-bone test can be helpful - a positive test in the presence of a clinically infected wound is highly suggestive of osteomyelitis 3

Definitive diagnosis requires bone culture and histopathology 3, 2
Percutaneous bone biopsy should be considered when clinical and imaging evaluations result in uncertain diagnosis, soft-tissue cultures are inconclusive, or infection fails to respond to initial empirical antibiotic therapy 1

For fractures with suspected infection, obtain inflammatory markers to establish baseline and monitor treatment, and perform wound cultures from tissues closest to the bone 1, 4
Start empiric antibiotic therapy targeting likely pathogens after obtaining cultures 2, 4
Consider surgical consultation, especially for moderate to severe infections 2, 4
Surgical intervention is indicated when there is evidence of septic joint, subperiosteal collections or bone necrosis are present, or failure to respond to initial antibiotic management 1, 2