October 2022: A Case of Ankle Annihilation

“Has your ankle been a problem for a long time?"I felt a sense of déjà vu looking at my patient's foot. I had seen this before: Someone with diabetes who had worsening, long-standing ankle pain, and had seen various doctors over the years.As before, my patient's foot was swollen, without ulcerations or signs of cellulitis or acute trauma. Perhaps we would do better this time. We could optimize our resource utilization, have him spend less time in the emergency department, and offer better care.Still, we began with an x-ray, and predicted that this symptom was one that some people with diabetes develop chronically, related to the inability to feel their feet.  Yep, it was ankle annihilation again. The patient's talar dome had completely dislocated and now pointed down toward the sole. It was easy to see the cause of the medial arch collapse and the appearance of a rocker-bottom deformity. All the tarsal bones affected were associated with bony fragments and diffuse soft tissue swelling.This patient had a Charcot neuroarthropathy, not osteomyelitis. Not infrequently, these patients will have erythema of the foot. But unlike cellulitis, the redness will dissipate when the leg is elevated. Instead of rushing toward a CT scan and lab work, I searched the electronic medical records for previous foot x-rays. As I suspected, the patient's issue was chronic.Recommendations from the emergency department: Off-load any pressure on the foot and follow up with po...
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