Case 38: Outpatient Treatment of Persistent Osteomyelitis of the Big Toe

At age 77, this diabetic male had been hospitalized for a month at a nearby Medical Center in Texas for osteomyelitis of the distal phalanx of his left big toe. Pus had continued to drain from the toe in spite of the month course of intravenous antibiotics in the hospital. He was discharged to continue ampicillin at home presumably treating the Hemophilus influenza that had been grown from his toe. He flew to Bryn Mawr in hopes of avoiding the uncertain surgery offered if his infection could not be cured.

He presented with an obviously swollen first toe that was reddened on its dorsal surface over the distal interphalangeal joint. Accompanying X-rays showed dissolution of the distal phalanx. His pedal pulses were absent. The Doppler wave forms at the ankle were low and greatly widened. Faint Doppler sounds were heard in the first dorsal metatarsal artery. He was treated as an outpatient in Bryn Mawr with seven injections of ampicillin (100mg in one ml sterile water), each followed by Mini-Boot therapy. His drainage promptly dried up, the fistula into the joint closed, the rubor receded and he returned to Texas. He telephoned periodically over the next year to report all was well.

Swollen Left Big Toe with Dorsal Rubor and Small Fistula

Dissolution of Distal Phalanx

Toe Healed and Fistula Closed

Comments: The hammer toes point to significant neuropathy accompanying the ischemia in this man. His treatment was straight forward.... and far, far, far cheaper than that he had endured at home.