Updated: 11/29/2017

Neuropathic (Charcot) Arthropathy

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Snapshot
  • A 50-year-old man presents with a swollen ankle joint. He reports having had a warm, swollen, and non-painful right ankle for about a year. His past medical history includes long-standing alcoholism, diabetes, and diabetic neuropathy with foot ulcers. On physical exam, his right ankle is warm, erythematous, and non-tender. Radiography reveals joint effusion and resorption of bone. Inflammatory markers are not elevated on laboratory evaluation.
Introduction
  • Clinical definition
    • arthropathy due to an underlying neuropathy or trauma, leading to destruction of joints and bone
  • Epidemiology
    • demographics
      • adults
    • location
      • foot and ankle (most common)
      • shoulder
      • elbows
    • risk factors
      • diabetic neuropathy
        • for foot and ankle disease
      • syringomyelia
        • for shoulder disease
      • syphilis
        • for knee disease
      • trauma
      • leprosy
  • Pathogenesis
    • autonomic neuropathy can result in hyperemia, which leads to increased osteoclastic resorption of the bone
    • peripheral neuropathy can result in loss of sensation and proprioception, which leads to unintentional repetitive trauma and injury
    • subsequent new bone formation and healing results in deformation of joints
  • Associated conditions
    • diabetes mellitus
    • tertiary syphilis
      • tabes dorsalis
    • chronic alcohol misuse disorder
    • syringomyelia
    • myelomeningocele
    • spinal cord tumors
Presentation
  • Symptoms
    • non-painful swelling of a joint
  • Physical exam
    • acutely, may present as non-tender, erythematous, edematous, and warm joint
    • chronically, may present as joint or foot deformity with joint effusion and bony prominences
      • most common deformity is a collapse of the tarsometatarsal joint with valgus angulation
    • may find other signs of chronic neuropathy, including foot ulcers
      • decreased or absent vibration sensation
      • loss of deep tendon reflexes
Imaging
  • Radiography 
    • indication
      • for all patients
    • findings
      • can be normal in early Charcot joint
      • acute
        • bony consolidation with fractures, joint effusion, or bone destruction
      • chronic
        • bony deformity, new bone formation, and sclerosis
        • resorption of bone
  • Magnetic resonance imaging (MRI) with gadolinium
    • indication
      • if radiograph is unclear and if osteomyelitis is suspected
    • findings
      • osseous edema
  • Bone scintigraphy (typically, technetium-99m-labeled methylene diphosphonate followed by indium-labeled leukocyte scintigraphy)
    • indication
      • to further distinguish neuropathic arthropathy from osteomyelitis
    • findings
      • negative (cold) for neuropathic arthropathy
      • positive (hot) for osteomyelitis
Evaluation
  • Labs
    • typically, normal leukocyte count and markers of inflammation (erythrocyte sedimentation rate and C-reactive protein)
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Cellulitis
    • distinguishing factor
      • no bony deformities or changes on imaging
  • Osteomyelitis
    • distinguishing factor
      • increased inflammatory markers
      • MRI and bone scintigraphy findings of osteomyelitis
Treatment
  • Conservative
    • immobilization and rest
      • indication
        • for all patients, especially in the acute phase
    • accommodative footwear
      • indication
        • for all patients, especially in the chronic phase
  • Operative
    • surgical repair
      • indications
        • only recommended for severe deformities
        • not usually performed
Complications
  • Spontaneous fractures
  • Osteomyelitis
 

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