GoutI Neuropathic Arthropathy

Gout Neuropathy Big Toe
Fig. 8.74 Loss of joint space and sclerosis are present—predominantly in the left base joint of the big toe. The large defects of the head of the metatarsal bone of the first toe are caused by gout tophi.

imitates an exostosis or a bunion. Pain and inflammation are frequent findings due to the unphysiological biome-chanical stress on the joint (Fig. 8.75).

If this patient had a neuropathy (for example, as a consequence of severe diabetes), one would have to consider another diagnosis:

Fig. 8.75 Hallux valgus is characterized by a lateral subluxation of the proximal phalanx in relationship to the first metatarsal with a resulting palpable bony protuberance lateral to this joint.

Misaligned Metatarsal
Fig. 8.76 Diabetes is one of the most frequent causes of a neuropathic arthropathy. In this case the whole upper ankle joint and the talus are destroyed. The bones stand misaligned. This may also occur in the first metatarsophalangeal joint.

Neuropathic arthropathy: A neuropathic arthropathy causes destruction and complete mutilation (Fig. 8.76), particularly of the large and heavily stressed affected joints. The cause of the damage is thought to be a combination of the sensory loss and vascular insufficiency. The joints suffer from a chronic biomechanical overload; associated pain that would normally prevent further use of the joint beyond its physical limits is not adequately perceived by the patient. Neuropathic arthropathy, particularly of the lower extremities, was also often seen in patients with neurosyphilis and was initially called "Charcot joint." Today the term applies to any neuropathic arthropathy.

• Diagnosis: While Ajay still ponders gout as the diagnosis—he has seen his grandfather suffer from it—Joey has made up his mind that this is a typical hallux valgus. Pavarocki's dancing must have aggravated the situation. However, this sort of weekend would also go along beautifully with a gout attack—the famous podagra.

f If the patient history always pointed us in the right diag-i nostic direction, imaging would be a useless exercise. For a radiologists this means: First analyze the image and get your thoughts organized, then check the clinical history, and at the end review the study again with both biased and unbiased information in your mind.

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