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Suspected diabetic foot osteomyelitis — SCE Geriatric Medicine MCQ

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HardTissue ViabilitySuspected diabetic foot osteomyelitisSCE Geriatric Medicine

An 83-year-old man with type 2 diabetes, peripheral neuropathy and stage 3 chronic kidney disease presents with a plantar ulcer beneath the first metatarsal head. The ulcer has been present for 10 weeks despite pressure-relieving footwear. It is now 12 mm deep, with purulent discharge and 1.5 cm of surrounding erythema. He is afebrile and haemodynamically stable, can take oral medication, and has palpable pedal pulses. The white cell count and C-reactive protein are normal. Plain radiography shows no cortical erosion, and probe-to-bone testing is negative. There is no fluctuance, necrosis or rapidly progressive inflammation. Which is the most appropriate immediate management?

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

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Correct answer: D — Refer immediately to acute services and inform the multidisciplinary foot care service, obtain a deep microbiological sample, start oral antibiotics promptly and arrange magnetic resonance imaging

Explanation lettering: C = shown as A · A = shown as B · E = shown as C · B = shown as E

The chronic, deep ulcer with new purulence and surrounding inflammation creates clinical concern for a deep-seated infection, including osteomyelitis. Normal inflammatory markers, a negative probe-to-bone test and an initially normal radiograph do not exclude diabetic foot osteomyelitis. NICE therefore supports MRI when osteomyelitis remains suspected but is not confirmed by initial radiography. Concern about deep soft-tissue or bone infection also requires immediate referral to acute services and notification of the multidisciplinary foot care service, rather than routine referral within 1 working day. A soft-tissue or bone sample from the base of the debrided wound should be obtained for microbiology, ideally before or close to antibiotic initiation. Treatment should not be delayed for MRI. As he is stable, can swallow and has no feature requiring intravenous treatment, an appropriate oral regimen is suitable initially. A under-triages a potentially limb-threatening infection. B uses a less informative superficial swab and CT rather than MRI. C correctly prioritises referral and deep sampling but incorrectly delays antibiotics. E would be appropriate for systemic illness, necrosis, an abscess or another surgically urgent infection; none is present here, and neither intravenous treatment nor immediate surgery is automatically required.

Reference: Diabetic foot problems: prevention and management — Recommendations (Last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations Diabetic foot problems: prevention and management — Recommendations (Last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations Diabetic foot problems: prevention and management — Recommendations (Last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations