Association of injury with neuropathic bone and joint disease

Abstract

Although Charcot described neuropathic joints over a century ago, their various forms still present the clinician with difficult decisions, especially in relation to injury. In the western world, diabetes mellitus is now the commonest condition associated with neuropathic bone and joint disease. A classical Charcot joint associated with diabetes was first described by Jordan in 1936, but other patterns of bone and joint disease have subsequently been described (Pogonowska et al., 1967; Forgacs et al., 1972; Newman, 1979). Injury would appear to modify the disease in several ways. Firstly, long bone fractures associated with neuropathy often form excessive callus (Figure I) in much the same way as in patients with spina bifida, burns, and head injuries. Secondly, trauma, or indeed forefoot surgery(Figure LX,&), can precipitate the development of the typical neuropathic Charcot joint (Newman, 1981). It has been suggested that the altered mechanics of walking throws an abnormal stress on the sensory deprived joint so that arthropathy develops. The destructive joint changes which develop after injury can be not only rapid but dramatic (Figure 3a,b) and may follow a mere sprained ankle (Slowman-Kovacs et al., 1990). Although it is difficult to prevent a problem developing, minor injuries of the foot in diabetics with neuropathy should be taken seriously. Patients usually present with swelling, redness and increased warmth in the foot, Often the neuropathy is not gross and initially the condition may cause pain. If there are any signs of a Charcot joint developing, then the foot needs prolonged protection to try to prevent deformity. This can usually be done in a weight-bearing cast, though Clohisy and Thompson (1988) recommend non-weight-bearing, but warn against development of similar changes in the opposite leg which then becomes subjected to abnormal loads. Eventually the disease will become burnt out and the foot stable but stiff. Provided no deformity has been allowed to develop, ulceration should not occur and the foot should function well, merely requiring appropriate footwear. The third association of injury with neuropathic musculoskeletal disease relates to spontaneous fractures. Small periarticular fractures are seen cormnonly in association with neuropathic joint destruction and should be regarded as part of the disease process. However, a different condition, first described by Heiple (1966) also exists in which a spontaneous fracture occurs without development of subsequent Charcot changes in the neighbouring joints (Fignres4, 5). These cases merely require recognition and non-operative