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Acute Charcot arthropathy — MSRA MCQ

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Hardall topics relevant for this examAcute Charcot arthropathyMSRA

A 61-year-old man with type 2 diabetes and stage 4 chronic kidney disease presents with a 10-day history of swelling and redness of his left foot. It began after he stepped awkwardly off a kerb. He reports little pain and has continued walking. Examination shows diffuse warmth and swelling over the midfoot, with a skin temperature 3°C higher than the contralateral foot. The skin is intact, with no ulcer or discharge. Pedal pulses are palpable, but 10 g monofilament sensation is absent. He is afebrile, the calf is soft and non-tender, and CRP and white cell count are normal. A weight-bearing foot and ankle X-ray shows no fracture, dislocation or bony destruction. Which is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: A — Advise non-weight-bearing and refer within 1 working day to the multidisciplinary foot care service

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

This is suspected acute Charcot arthropathy: an unexplained hot, swollen foot with intact skin in a person with diabetic peripheral neuropathy. Stage 4 chronic kidney disease further increases the clinical suspicion. Charcot arthropathy may cause little or no pain, and early plain radiographs can be normal. A normal X-ray must therefore not override the clinical findings; MRI can be considered by the appropriate pathway if suspicion persists. NICE recommends referral within 1 working day to the multidisciplinary foot care service, with non-weight-bearing treatment while definitive assessment and offloading are arranged. A is inappropriate because there is no ulcer, portal of entry, purulent discharge or systemic evidence supporting diabetic foot infection; antibiotics should not be used for non-infective inflammation. B may initially suggest gout after minor trauma, but the profound neuropathy, minimal pain and marked temperature asymmetry favour Charcot arthropathy, for which continued loading risks structural collapse. C is inappropriate because the swelling is centred on the foot without calf features suggesting deep-vein thrombosis, and unrestricted weight-bearing is hazardous. D recognises a mechanical process, but protected weight-bearing and routine fracture-clinic referral provide insufficient offloading and urgency; suspected Charcot arthropathy requires the multidisciplinary diabetic foot pathway.

Reference: Diabetic foot problems: prevention and management — Recommendations (Published 26 August 2015; last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations