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Suspected diabetic foot osteomyelitis — MSRA MCQ

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ModerateAnkle and FootSuspected diabetic foot osteomyelitisMSRA

A 69-year-old man with type 2 diabetes attends the GP surgery because of a plantar ulcer beneath the right first metatarsal head. He has peripheral sensory neuropathy and CKD G3a. The ulcer has been present for 5 weeks and has become more painful over the past 3 days. He is afebrile and systemically well. Dorsalis pedis and posterior tibial pulses are palpable, and the foot is warm with normal capillary refill. There is a 1.6 cm ulcer with 8 mm depth, a small amount of purulent discharge and erythema extending 0.8 cm beyond the ulcer margin. Sterile probing reaches hard bone. There is no crepitus, lymphangitis, gangrene or pain out of proportion. CRP and white cell count are within reference ranges. Plain foot radiographs show no bony destruction. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Refer immediately to acute services and notify the multidisciplinary foot care service

Explanation lettering: D = shown as A · A = shown as D

This ulcer raises clinical concern for diabetic foot osteomyelitis: it is chronic and deep, has local infective features, and probes to bone. NICE classifies clinical concern for deep-seated soft-tissue or bone infection as a limb-threatening diabetic foot problem requiring immediate referral to acute services, with notification of the multidisciplinary foot care service. Normal inflammatory markers and normal initial plain radiographs do not exclude osteomyelitis in this setting. A is inappropriate because active infected diabetic foot disease requires specialist triage rather than routine community follow-up. B would be appropriate for an active diabetic foot problem without limb-threatening features, but suspected bone infection crosses the threshold for immediate acute assessment. D is incorrect because MRI may be needed if osteomyelitis remains unconfirmed after radiography, but arranging it as an outpatient must not delay urgent assessment. E recognises infection, but oral antibiotics and short-interval primary-care review alone are insufficient where deep infection or osteomyelitis is suspected; assessment, imaging strategy, sampling and antimicrobial management require urgent secondary-care input.

Reference: Diabetic foot problems: prevention and management (NG19) — Recommendations (Published 2015; antimicrobial recommendations updated 2019; page checked August 2026) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations Diabetic foot problems: prevention and management (NG19) — Recommendations (Published 2015; antimicrobial recommendations updated 2019; page checked August 2026) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations Diabetic foot problems: prevention and management (NG19) — Overview (Last updated October 2019; last reviewed July 2025) — https://www.nice.org.uk/guidance/ng19