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Endocrine Abstracts (2014) 34 P104 | DOI: 10.1530/endoabs.34.P104

Department of Endocrinology and Diabetes, Royal Cornwall Hospital, Truro, UK.

In patients with diabetes an isolated ‘sausage toe’ is suggestive of underlying osteomyelitis. Neuropathic (Charcot) arthropathy, devastating complication of diabetes, normally presents in the midfoot and can be precipitated by surgery or minor trauma.

We report a 62-year-old man with a 2-year history of well controlled type 2 diabetes (HbA1c 56 mmol/mol), with no micro or macro vascular complications, referred to diabetic podiatrist with a hot, red, swollen, left hallux (sausage toe appearance) 8 weeks following minor trauma. The temperature difference between left and right hallux was 6.0–8.1 °C. Examination of the fore and midfoot was normal, all pedal pulses were biphasic, there was objective peripheral neuropathy. Initial appearances suggested underlying osteomyelitis but blood results were not supporting this: WCC 8.5 10×9/l, CRP 2.1 mg/l. X-rays revealed fragmentation of the distal phalanx compatible with previous crush fracture but clinical suspicion of osteomyelitis remained high.

Subsequent MRI suggested fracture of the terminal phalanx of the left hallux with surrounding extra osseous calcification and ossification but no definite evidence of associated infection.

In view of normal inflammatory markers no antibiotic therapy was initiated and conservative management (off loading, foot wear) adopted. Repeat CRP and WCC stayed within the normal limits although the hallux remained swollen and warm (7.5 °C temperature difference). After 4 months X-ray appearances progressed to show destruction at the interphalangeal joint yet clinically the toe improved with reduced swelling and temperature. A diagnosis of localised hallux Charcot was made. Two months later the patient presented with classical Charcots of the right midfoot with typical radiological changes.

Localised Charcot changes of the Hallux is not widely reported but should be considered in the differential of a hot swollen hallux prior to assuming a diagnosis of osteomyelitis. Clinicians must be aware of these unusual sites of Charcot’s arthropathy.

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