Age / Sex : 51 / M

Chief complaint: Rt foot pain, heat sensation and redness during about 10 days

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.)

Courtesy: 이상용 (Lee Sang Yong), 전북대학교병원 (Chonbuk national university hospital)

Charcot joint

Discussion

Findings:

The AP view of the right foot shows irregular bone erosions and joint space narrowing in multiple tarsometatarsal joints. Vascular wall calcification is also noted.

Transverse CT images show multiple bone erosions and marginal sclerosis in the bases of the 4^th and 5^th metatarsal bones and intermediate cuneiform; those are associated with soft tissue swelling.

Sagittal T2-weihgted MR image shows joint space narrowing, bone marrow edema and synovitis of the cuboidometatarsal joint and lateral cuneiform metatarsal joints. On T1-weihted transverse MR image shows diffuse low-signal intensities of the multiple metatarsal bones. Fat-suppression T1WI with contrast enhancement shows strong enhancement of the joints, adjacent bone marrow spaces and surrounding soft tissue.

Differential Diagnosis:

1) Multifocal septic arthritis with osteomyelitis

2) Post-traumatic osteolysis

3) Neuropathic arthropathy

Diagnosis: Charcot joint (Neuropathic joint)

Discussion:

-       Severly and rapidly destructive joint process

-       Predisposing fractors : 1) Diabetes

                     2) Tabes dorsalis

                     3) Congenital insensitivity to pain

                     4) Alcoholism, steroid use

 -   General features

* Best diagnostic clue: “5Ds”

 1) Normal bone density for patient

 2) Joint distension

 3) Bony debris

 4) Cartilage destruction

 5) Joint disorganization or dislocation

- Location (foot and ankle)

: Lisfranc (tarsometatarsal) > talonavicular > intertarsal > Chopart joint

- Radiographic findings

n  Large effusion distending joint

n  Bony debris

n  Normal bone density

n  Mixed erosive and productive osseous change

n  Ligamentous laxity with joint subluxation/dislocation

n  Articular destruction

References:

1.     Ahmadi ME et al : Neuropathic arthropathy of the foot with and without superimposed osteomyelitis : MR imaging characteristics. Radiology. 238(2):622-31, 2006

2.     Ledermann HP et al : Differential diagnosis of pedial osteomyelitis and diabetic neuroarthropathy: MR Imaging. Semin Musculoskelet Radiol. 9(3):272-83, 2005