skip to main content

Acute Charcot arthropathy — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

Hardall topics relevant for this examAcute Charcot arthropathyMSRA

A 58-year-old man with type 2 diabetes mellitus attends with a 5-day history of a swollen, red and warm left midfoot. Symptoms began after he misjudged a kerb but he does not recall a significant injury. He reports little pain and has continued to walk to work. He has marked loss of protective sensation in both feet on monofilament testing and CKD G4. The skin is intact, with no ulceration or discharge. He is afebrile and systemically well. Pedal pulses are palpable bilaterally. CRP is 4 mg/L and white cell count is normal. A non-weight-bearing foot radiograph arranged at an urgent treatment centre yesterday was reported as normal. What is the most appropriate management now?

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

Reveal the answer and explanation

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

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

This presentation is strongly suggestive of acute Charcot arthropathy: a hot, swollen, erythematous foot with intact skin in a person with diabetes, profound peripheral neuropathy and renal impairment. Minimal pain and absence of established deformity do not reduce concern; neuropathy may mask pain, and early Charcot changes may not yet be visible on plain radiography. The normal non-weight-bearing radiograph therefore does not justify continued walking or delayed specialist assessment. NICE recommends non-weight-bearing treatment while definitive management is arranged, weight-bearing radiographs of the foot and ankle, and referral within 1 working day to the multidisciplinary foot care service, with triage within a further working day. MRI is considered if radiographs are normal but suspicion remains, but it should not delay referral or immediate offloading. A is inappropriate because there is no ulcer, purulence, systemic illness or inflammatory-marker support for diabetic foot infection. B is plausible for an acutely inflamed foot but misses the high-risk neuropathic Charcot pattern. C includes offloading but delays specialist assessment and appropriate imaging. D recognises diagnostic uncertainty but permits weight-bearing and incorrectly sequences MRI before urgent specialist referral.

Reference: NICE NG19: Diabetic foot problems: prevention and management — Recommendations, sections 1.4 and 1.7 (Last updated 11 October 2019; relevant active-foot-problem definition reviewed 2023) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations