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Updated: Nov 29 2017

Neuropathic (Charcot) Arthropathy

Images shoulder.jpg shot 2017-11-25 at 3.24.41 pm.jpg
  • 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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