case_images: PMC6159173_01
case_images: Radiograph of the left foot demonstrates callus formation at the diaphysis of the second, third, fourth and fifth metatarsals, consistent with stress fractures.
case_images: bjrcr.20170026.g001.jpg
case_images: PMC6159173_01_bjrcr.20170026.g001.jpg
case_images: f1
case_images: Radiograph (Figure 1) demonstrates multiple healing stress fractures involving the diaphysis of the second, third, fourth and fifth metatarsals.
case_images: PMC6159173_02
case_images: (a) Right foot radiograph 6 months prior to presentation demonstrates an ununited fracture of the proximal shaft of the fifth metatarsal (arrow). Note exuberant callus formation and sclerotic bone margins, likely representing a post fracture pseudarthrosis. (b,c) Right foot radiograph (b) of the same patient performed for investigation of new foot swelling, followed by MRI (c). Radiograph (b) demonstrates collapse and sclerosis of the second, third (arrow) and fourth metatarsal heads. Note associated cortical thickening of the metaphyses and diaphyses. Axial post gadolinium fat-suppressed T1 sequence (c) demonstrates increased signal in the third, fourth and fifth metatarsal heads and bone marrow oedema with no significant soft tissue involvement, confirming avascular necrosis.
case_images: bjrcr.20170026.g002.jpg
case_images: PMC6159173_02_bjrcr.20170026.g002.jpg
case_images: f2
case_images: Radiograph performed 6 months prior to presentation (Figure 2a) shows an ununited fracture of the proximal shaft of the fifth metatarsal. Six months later, a radiograph (Figure 2b) performed for investigation of painless foot swelling demonstrates changes consistent with avascular necrosis of the heads of the second, third and fourth metatarsals. MRI (Figure 2c) confirmed the findings.
case_images: PMC6159173_03
case_images: Radiopraph of the left foot demonstrates flattening of the heads of the second (arrow) and third metatarsals, consistent with established avascular necrosis. Note associated diffuse cortical thickening along the metaphyses and diaphysis of the involved metatarsals, commonly seen in avascular necrosis.
case_images: bjrcr.20170026.g003.jpg
case_images: PMC6159173_03_bjrcr.20170026.g003.jpg
case_images: f3
case_images: Radiograph of the left foot (Figure 3) demonstrates established avascular necrosis involving the heads of the left second and third metatarsals.
case_images: PMC6159173_04
case_images: (a) Oblique radiograph of the left foot demonstrates previous amputation of the second toe and an ununited fracture of the head of the proximal phalanx of the fourth toe, probably secondary to previous trauma in an insensate foot. Furthermore, there is "pencil point" deformity of the neck of the proximal phalanx of the fourth toe (arrow). Cortical irregularity at the head of the third metatarsal raises suspicion of osteomyelitis. (b) Left foot radiograph of the same patient performed 5 years earlier, shortly after amputation of the second metatarsal, demonstrates normal appearance of the phalanges of the fourth toe.
case_images: bjrcr.20170026.g004.jpg
case_images: PMC6159173_04_bjrcr.20170026.g004.jpg
case_images: f4
case_images: Radiograph performed on presentation (Figure 4a) shows an ununited fracture of the head of the proximal phalanx of the fourth toe, consistent with previous trauma in an insensate foot. "Pencil point" deformity of the neck of the proximal phalanx of the fourth toe is compatible with bone remodelling, most likely related to chronic microtrauma associated with profound sensory neuropathy and altered biomechanics secondary to previous amputation. A radiograph (Figure 4b) performed 5 years earlier shown for comparison demonstrates normal appearance of the proximal phalanx of the fourth toe.
case_images: PMC6159173_05
case_images: MRI axial post gadolinium fat suppressed T1 sequence (a) and sagittal reformatted CT (b) demonstrate resorptive remodelling of the distal phalanx of the fifth toe (arrow). Surrounding soft tissue enhancement (dashed arrow) is noted on the MRI.
case_images: bjrcr.20170026.g005.jpg
case_images: PMC6159173_05_bjrcr.20170026.g005.jpg
case_images: f5
case_images: MRI (Figure 5a) and CT (Figure 5b) demonstrate remodelling of the distal phalanx of the fifth toe.
case_images: PMC6159173_06
case_images: (a) Lateral radiograph of the left foot demonstrates a posterior calcaneal spur, but otherwise normal appearance of the calcaneum. (b,c) MRI coronal T2 fat suppressed sequence (b) demonstrates signal hyperintensity in the anterior calcaneus, which extends from the medial to the lateral cortex, with corresponding low signal on coronal T1 sequence (c). Findings are consistent with a non-displaced fracture. A soft tissue defect at the heel (not shown) does not extend to the calcaneal cortex. Remaining calcaneal signal (not shown) is normal with no evidence of osteomyelitis.
case_images: bjrcr.20170026.g006.jpg
case_images: PMC6159173_06_bjrcr.20170026.g006.jpg
case_images: f6
case_images: Radiograph of the left calcaneus (Figure 6a) was unremarkable. MRI (Figure 6b,c) reveals a non-displaced insufficiency fracture of the calcaneus with no evidence of osteomyelitis.
case_images: PMC6159173_07
case_images: Radiograph of the left foot demonstrates a dressing overlying a heel ulcer and a wedge-shaped calcaneal avulsion fracture (arrow) at the posterior calcaneum.
case_images: bjrcr.20170026.g007.jpg
case_images: PMC6159173_07_bjrcr.20170026.g007.jpg
case_images: f7
case_images: Radiograph of the left foot (Figure 7) reveals a wedge-shaped avulsion fracture at the posterior calcaneus.