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Acute Charcot arthropathy — MSRA MCQ

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ModerateAnkle and FootAcute Charcot arthropathyMSRA

A 59-year-old man with type 2 diabetes attends general practice with a 3-day history of swelling and redness affecting his left midfoot. He recalls misstepping off a low kerb shortly before the symptoms began but did not consider this a significant injury. He has established peripheral sensory neuropathy and CKD G3a. He reports little pain and has continued walking on the foot. He is afebrile and systemically well. The left midfoot is diffusely warm, swollen and erythematous compared with the right. The skin is intact, with no ulceration, discharge or interdigital maceration. There is no calf swelling. Pedal pulses are palpable and capillary refill is normal. CRP and white cell count are within reference ranges. What is the most appropriate management today?

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

Reveal the answer and explanation

Correct answer: E — Arrange weight-bearing foot and ankle radiographs, make him non-weight-bearing, and refer within 1 working day to the multidisciplinary foot care service

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

This presentation is suspicious for acute Charcot arthropathy: a unilateral hot, swollen, erythematous foot with intact skin in a person with peripheral neuropathy and renal impairment. Pain may be minimal despite substantial bone and joint injury, so his ability to continue walking does not reassure. The minor preceding trauma further supports the possibility of Charcot change. NICE advises arranging weight-bearing radiographs of the affected foot and ankle when acute Charcot arthropathy is suspected. Crucially, he should be kept non-weight-bearing while awaiting definitive specialist management and referred within 1 working day to the multidisciplinary foot care service. A normal initial radiograph would not exclude Charcot arthropathy; MRI should be considered if suspicion persists. A is initially plausible because the foot is red and warm, but there is no skin breach, systemic illness, inflammatory-marker rise or focal infective source. B is less likely because gout usually causes marked pain and focal joint inflammation. C is inadequate because non-weight-bearing films may miss early instability and it delays the required urgent referral. D would be appropriate for a limb- or life-threatening diabetic foot problem, such as sepsis, deep infection, gangrene or ulceration with ischaemia, none of which is present.

Reference: NICE NG19: Diabetic foot problems: prevention and management — Recommendations (Published 2015; last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations NICE NG19: Diabetic foot problems: prevention and management — Recommendations (Published 2015; last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations