Diabetic Foot – Approach to Charcot Arthropathy

The classic case is the patient who arrives with swelling and discomfort in his foot after a “sprain” or minor trauma some months ago – he may or may not have been diagnosed with diabetes. This may be the presenting complaint!

– pain characteristics WWF CART
– diabetic things to rule out: frequency, nocturia, thirst, weight loss
– symptoms of peripheral vascular disease
– symptoms of numbness/tingling, other wounds, fungal infections of the toes
– progressive deformity in the foot?

– motor and sensory testing is key – what is the pattern of sensory loss – pinprick, light touch, vibration/proprioception
– signs of autonomic dysfunction – skin dystrophic changes, hair loss, hyperemia, dry skin
* look for signs of pressure breakdown
– assess the deformity – ankle, hindfoot, midfoot, forefoot

– look at the x-ray and try to make out what “Eichenholtz” stage this is
I – Dissolution (demineralization)
II – Coalescence (early healing)
III – Resolution (sclerosis and ankylosis)
– Basically, everything is NO TOUCH until the resolution stage III because of severe osteopenia and the inability to achieve good fixation and instability of the skin for healing.
– the initial treatment is therefore NON-operative.
– they are NON-WEIGHTBEARING for up to 9 months – arrange for electric wheelchair; then TEMPORIZE
– Foot up for a few days to get swelling down
– Then some form of orthosis to prevent pressure and shear: foam walker boot with soft tri-density accommodative insoles, or total contact casting, or patellar tendon clamshell brace
– They are in this for up to 9 months!

There are 3 indications to operate
1. infection – either local or spreading/systemic needs aggressive I & D or amputation
2. prophylactic pressure relief – if osseous deformity is creating a pressure ulcer that, if left untreated, will eventually break down, you might as well do the oste-ectomy to get rid of the pressure point. Good example is the LisFranc injury with prominence over the cuboid and laterally displaced 5th metatarsal – you can knock off the lateral aspect of the cuboid and metatarsal.
3. stabilization of a fracture once it is safely into the resolution stage if there is ongoing instability and pain.

Total contact casting
– pads for the pressure areas, 1 layer of soft-roll
– well moulded PLASTER cast
– cover the toes!

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