Ulcer to tip of toe with bone changes and infection

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I would like to tell you a little story about a patient in Worcester, MA. She was seen in my office for an ulcer to the tip of her second toe. She tends to have this toe that is a little bit longer than the other toes. A lot of women do not like this because it rubs in their shoe. In her case she developed a callus to the tip of this toe. After many years of having this callus eventually it developed into a sore or wound that got infected. We treated it, it got better, then it got worse, then it got better again, but eventually what happened is the ulcer at the tip of the toe never really healed. An x-ray was performed and it looked pretty normal, but then a few months later, after she had an MRI, we obtained a followup x-ray and you can see the picture here. There is the tip of the toe on the right-hand side that is nice and intact at the tuft of the distal tip of it; and then you can see the one right next to it where the tip of the toe actually looks like it is cut off there at the tip of the toe. You can see that is due to changes in the bone called osteomyelitis or bone infection. You can also see in the picture below this little callus on the top, at the tip of it, that does not look too bad. It is not actively infected, there is no redness, it does not bother her, but it is just that the sore never healed.

The reason the sore will not heal is because of four reasons: (1) you are walking on it, (2) there is poor blood flow, (3) your blood sugar is out of control, or (4) there is a deeper infection. In this case she has a deeper infection called osteomyelitis that is in the bone. Even though the skin is not infected, the bone underneath it is and the best type of treatment for this is to actually remove that portion of the bone which we are going to do in the next few weeks.