It has been a little while since I asked a clinical question of you, the readers. I actually received a pretty good response last time and some interesting thoughts so I figured I would post a question that was recently asked of me:
“What is your opinion on the ‘standard of care’ of the need for serial imaging (x-rays in particular but also possibly MRI or nuclear scans can be considered) in a chronic plantar wound, in a patient with diabetes? The wound does not probe and there are no signs of clinical infection. The wound is probably not healing because of non-adherence with off loading instructions. How often would you order the different imaging studies?”
The reason I am bringing this up to you is that I think it is a really interesting question. What do you think? Please respond and let me know. After I hear from you, I will try to give you my thoughts on it.
If serial X-rays negative, and no clinical signs, eg tunneling, no further imaging
Weight-bearing radiographs to fully evaluate biomechanics in order to determine the proper shoe/orthotic.
No need for further imaging as there are no signs of deeper infection
I use my “Harry Potter” magic wand and if there is an infections it is
drawn magically to the area. (Outside the box enough ?)
In my community, its MRI, and if that does not help, then CT guided bone biopsy. Of course, I still like x-rays, but the radiologist
always request MRI before they will say its osteo……
Monthly plain films x 2, then Q 60 D as long as clinical picture does not worsen. MRI or nuclear studies only to confirm clinical suspicion of OM.
Lacking clinical signs of infection and in suspicion of noncompliance, I would get radiographs, due to their clinical relevance and easy access. If a set of radiographs was negative as well, I would continue to treat the ulcer based on the clinical presentation. You could pursue more expensive tests to protect yourself legally, but if there is no clinical sign of infection, then from a medical standpoint what is prompting the test. In short I think your treatment should be guided by clinical suspicion and medical standard of care first. That being said, we live in an extremely litigious society and as a medical practitioner, protecting your assets is also a reality, so further investigation might just come down to whether you live in Philadelphia versus Brush prairie.