Can osteomyelitis develop with a nondisplaced intra-articular fracture of the proximal phalanx of the great toe?

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

Yes, osteomyelitis can develop with a nondisplaced intra-articular fracture of the proximal phalanx of the great toe, particularly when there is an associated open wound or contamination pathway. 1

Risk Factors and Pathophysiology

• Fractures that communicate with the external environment (open fractures) have a direct pathway for bacterial contamination, significantly increasing osteomyelitis risk 2, 3
• Even seemingly minor injuries like "stubbed toes" can result in occult open fractures that lead to osteomyelitis if not recognized and treated promptly 2, 4
• 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 1

Diagnostic Approach

• 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, 5
• 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 CRP >3.2 mg/dL combined with clinical findings (ulcer depth >3 mm) help differentiate osteomyelitis from cellulitis 1, 6
• The probe-to-bone (PTB) test, where a sterile blunt metal probe is used to explore foot wounds, can be helpful - a positive test (palpable hard, gritty bone) in the presence of a clinically infected wound is highly suggestive of osteomyelitis 1

Diagnostic Confirmation

• Definitive diagnosis requires bone culture and histopathology 1
• Percutaneous bone biopsy should be considered when:
  • Clinical and imaging evaluations result in uncertain diagnosis 1
  • Soft-tissue cultures are inconclusive 1
  • Infection fails to respond to initial empirical antibiotic therapy 1
  • Considering an antibiotic regimen with higher potential for selecting resistant organisms 1

Management Approach

• For fractures with suspected infection:

  • Obtain inflammatory markers (ESR, CRP) to establish baseline and monitor treatment 5, 6
  • Perform wound cultures from tissues closest to the bone (avoid swab cultures due to contamination risk) 1, 5
  • Start empiric antibiotic therapy targeting likely pathogens after obtaining cultures 1, 5
  • Consider surgical consultation, especially for moderate to severe infections 1, 5

• Surgical intervention is indicated when:

  • There is evidence of septic joint (requires immediate surgical debridement) 1
  • Subperiosteal collections or bone necrosis are present 1
  • Failure to respond to initial antibiotic management 1

Complications and Prognosis

• Delayed diagnosis and treatment of open fractures significantly increase the risk of developing osteomyelitis 2, 3
• Intra-articular fractures of the great toe have a high complication rate even after surgical intervention 7
• Potential complications include:
  • Nonunion or malunion of the fracture 7, 4
  • Posttraumatic arthritis 7
  • Growth arrest in pediatric patients 2, 3
  • Chronic osteomyelitis requiring prolonged antibiotic therapy 1, 2

Prevention

• Early recognition of potential open fractures, even when not clinically obvious 2, 3
• Prophylactic antibiotics for open fractures or those with high contamination risk 2, 4
• Thorough debridement of contaminated wounds 1, 8
• Close monitoring of fracture healing and infection markers 5, 6

Careful attention to these principles can help prevent the development of osteomyelitis in patients with nondisplaced intra-articular fractures of the proximal phalanx of the great toe, or facilitate early diagnosis and treatment if infection does occur.