The Forgotten Toe

A 62-year-old man with type 2 diabetes (HbA1c 9.8%), peripheral arterial disease (ankle-brachial index 0.6 on right), and neuropathy presents with a 4-month history of a non-healing plantar ulcer beneath his right first metatarsal head. The ulcer began as a small blister after wearing new shoes and has progressively deepened, now measuring 3 × 2 cm with a fibrinous base and exposed bone at the base. He reports minimal pain due to neuropathy but endorses low-grade fevers over the past two weeks. He has no history of recent antibiotics or hospitalizations.

On examination, temperature is 37.9°C, heart rate 92, blood pressure 148/86 mmHg. Right foot examination reveals a deep plantar ulcer with surrounding erythema and mild edema. A sterile probe reaches bone. Sensation is absent to 10-g monofilament testing. Dorsalis pedis and posterior tibial pulses are faintly palpable with Doppler assistance. No crepitus or fluctuance.

Laboratory studies: WBC 12.4 k/mcL with 78% neutrophils, hemoglobin 11.8 g/dL, platelets 340 k/mcL. CRP 42 mg/L, ESR 58 mm/hr. Random glucose 284 mg/dL. Plain radiographs show cortical erosion and periosteal reaction of the first metatarsal. MRI confirms osteomyelitis with a 3-cm abscess tracking along the plantar fascia. The patient undergoes transmetatarsal amputation with intraoperative bone biopsy from the proximal margin, shown below.