Radiology Review

There’s Mischief Afoot

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There’s Mischief Afoot

A 70-year-old man presents for evaluation of left foot pain, redness, and swelling. He reports injuring the foot a week ago; he went to the emergency department for evaluation of the cut he had sustained, which required stapling.

The patient has a chronic foot ulcer for which a home health aide provides wound care and dressing changes. His medical history is significant for hypertension, stroke with chronic left-sided weakness, congestive heart failure, and chronic renal insufficiency. He admits to daily tobacco use, and his medical record reflects a history of drug use.

On physical exam, you note an elderly, chronically ill male in no obvious distress. His vital signs are stable, and he is afebrile. Inspection of his left foot shows generalized swelling and redness. Good distal pulses are appreciated. On the dorsal aspect, there is a healing wound with a single staple present. On the heel is a 2-cm stage 2 ulcer with some scant purulent drainage.

Bloodwork and a radiograph of the left foot are ordered; lateral view is shown. What is your impression?


There’s Mischief Afoot


The radiograph demonstrates no evidence of an acute fracture or soft-tissue gas to suggest an abscess. Of note, though, within the tibiotalar joint, the patient has bony destruction and settling of the articular surfaces of both the distal tibia and fibula into the talus and calcaneus.

This finding is typically associated with neuropathic arthropathy (also known as a Charcot joint). This pathologic process is typically seen in a weight-bearing joint that develops progressive degeneration from chronic loss of sensation.

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