Charcot Joint - Causes, Pathology, Radiology and Treatment

What is Charcot Joint?

  • Charcot joint, also known as neuropathic arthropathy, is a condition characterized by loss of sensation in the different joints of the body. It was first described by a French neurologist, Jean-Marie Charcot in 1868. [1]
  • This disorder is most commonly observed on diabetic patients who have had uncontrolled blood sugar levels for more than 10 years. Aside from loss of sensation, it is also characterized by instability of the affected joint. The loss of sensation increases the risk of patient experiencing accidents which can lead to further joint injury. [2]
  • The affected joint is dependent on the location of the nerve damage. In most cases, the weight-bearing joints such as the knee, ankle and spinal cords are involved. For those who have diabetes, injury to the ankle joints and other foot joints are the most common complaints because minor stimulus-causing pain is not easily felt. [3]

Causes of Charcot Joint

  • A potent nerve supply is highly important for the function of a joint. If the nerve supply is interrupted, it leads to degeneration of the cartilage which further results to bone fracture. As the loss of sensation aggravates the joint swells and gets distorted as well. [4]
  • The joint that is affected is a good starting point when identifying the cause of this disorder. It is possible that multiple joints are affected but having three affected joints at one time is highly unlikely.
  • Syringomyelia injures the wrist joint more while tabes dorsalis commonly affects the hip, knee and spine. Congenital sensitivity to pain targets the knee while diabetes can affect multiple joints such as the wrist, ankle, foot and spine. Other causes can include spinal cord injury, syphilis, steroid use, spina bifida and, scleroderma.

Pathology of Charcot Joint

  • Charcot joint can occur in two forms: atrophic or hypertrophic. Some experts say that both forms actually present on the patients, only that the atrophic form occurs earlier.

Picture : Charcot Joint of the Elbow

Source: emedicine.medscape.com
  • Atropic form. This is the more common form and occurs mainly on the upper limb joints such as the elbow. [5] In this form, there is observable reduction on the bone mineral density (BMD) and the amount of proteins stored in the bone. The bone undergoes resorption with no visibility of spurs and fragments.

Picture : Charcot Joint of the Shoulder

Source: emedicine.medscape.com
  • Hypertropic form. Unlike atropic form, there is no osteoporosis seen on this form but bone fractures and dislocations are noticeable in X-ray.[6]


Charcot Joint and Radiology

Radiology has been a good advancement in the medical field. This field made it possible for medical professionals to look at the internal parts of the body without invasive procedures. However, there is challenge on the diagnosis of charcot joint using radiology as almost all of the findings for this disorder can also be found for other disorders such as osteomyelitis.


Picture : Charcoat joint of the knee joint

Source: learningradiology.com

X-ray

This allows physicians to look at the general condition of the bones. The above picture shows marked hardening of the tissue, fragmentation and destruction of the joint.


Ultrasonography

This procedure allows physicians to check for infection and secure samples for further analysis.


Computed Tomography Scanning

This procedure is used to evaluate destruction of the cortex, separation of a piece of the dead bone, presence of intraosseous gas.


Magnetic Resonance Imaging & radionuclide scanning

These procedures are helpful in differentiating infection versus osteomyelitis. [7]



Source: http://radiographics.rsna.info

This X-ray image shows extensive resorption on the affected portion while bone mineralization is maintained for the remaining viable part of the humerus.






Source: http://radiographics.rsna.info

This image shows the chest radiograph of a 28-year-old patient who was diagnosed with neuropathic osteoarthropathy. The arrow pointing to the right shows the destruction of the glenohumeral joint, which can be asymptomatic. [8]


How do we Treat Charcot Joint?

Medical Therapy

Medical Therapy consists of two phases: acute and post-acute phase.
  • The acute phase is comprised of immobilization through casting and reduction of stress. A study has shown that acute phase can last more than 3 months, in which time the patient is advised not to bear weight on the affecting joint. Not doing so will increase the length by which the patient needs to wear the cast. The cast needs to be checked and replaced at regular timings. Additional care must be done in cases of ulceration.
  • After the cast is removed, the patient will need to wear a brace to protect the joint. Braces come on different types depending on the specific need they address. There are patellar tendon-bearing brace, double metal upright AFO and more. Patients will also be advised to use custom footwear as the normal footwear may lead to the recurrence of the disorder. In total, the healing process can take up to 2 years.


Surgical Therapy

There are also surgical procedures available for the management of Charcot joint. These include the following:
  • Exostosectomy of the bony prominence - removal of a non-cancerous growth on the bone surface
  • Osteotomy - shortening, lengthening or changing of the alignment of the bone [9]
  • Arthrodesis - fixation of a joint to encourage bone fusion
  • Screw and plate fixation
  • Open reduction and internal fixation
  • Reconstructive surgery
  • Fusion with Achilles tendon lengthening
  • Autologous bone grafting
  • Amputation

If fractures are left untreated, they can cause infection which can require amputation. Other complications include the formation of clubfoot, rocker-bottom foot, and plantar arch inversion, ligamentous ossification, extra-articular exostoses and even osteomyelitis.

It is important that a patient with the risk factors listed above visit a licensed physician to ensure that the condition is treated and managed, if not prevented. [10]

References:
  1. https://en.wikipedia.org/wiki/Jean-Martin_Charcot
  2. http://medical-dictionary.thefreedictionary.com/Charcot's+Joints
  3. http://en.wikipedia.org/wiki/Neuropathic_arthropathy
  4. http://www.healthcentral.com/encyclopedia/408/204.html
  5. http://radiopaedia.org/articles/charcot-joint
  6. http://www.footdrhorsley.com/health/charcot_foot.php
  7. http://emedicine.medscape.com/article/391989-overview
  8. http://radiographics.rsna.info/content/20/suppl_1/S279.full
  9. http://orthoinfo.aaos.org/topic.cfm?topic=A00591
  10. http://emedicine.medscape.com/article/1234293-treatment#a1128

Rash on Inner Thigh - Causes, Remedies and Treatment

Rashes are skin lesions usually characterized as erythematous, slightly inflamed, and with either pruritus or burning sensation. These can be found in any part, any inch of the human body. One of the most common locations of rashes is the inner thigh.

 

Causes of Inner Thigh Rashes

A variety of factors can cause these rashes. These agents may be as simple as irritant, to as complex as an infection.

 

Contact Dermatitis

Rashes may occur whenever the skin comes in contact with an irritant. This goes for every part of the body, including the thighs.

Contact dermatitis is a condition characterized by inflammation of the skin brought about by undesirable reactions to an irritant substance. These include bathing products, lotions, moisturizers, laundry detergents, and even the clothing itself, when made of synthetic fabric or an irritant dye. [1, 2, 3]

On contact, certain plant toxins, like poison ivy and poison sumac, can also cause such rashes. These skin lesions are described as disturbing, with severe itching, and if neglected, can even lead to anaphylaxis. One can acquire such rash either by travelling, or by obtaining it from a pet. [2]



Image 1 : This is a patient with contact dermatitis, with rashes seen at the inner thigh.

Source: www.thecrazygallery.info

Allergies

Hypersensitivity reactions to either food or medications can also lead to rashes localized on the inner thigh. Most of these may accompany generalized rashes and itching. The usual suspects include peanuts, shellfish and seafood, chicken, and eggs. Most of them are mild and can easily be handled, however, at times, it can also produce life-threatening effects on other organs such as the kidneys, heart, intestines and joints, and unfortunately, be fatal. [1, 2]



Image 2 : An allergic rash at the inner thigh.

Source: www.crazymeds.us

 

Atopic Dermatitis or Eczema

One of the most common causes of eczema is atopic dermatitis. It is a chronic skin condition resulting from hypersensitivity of the skin. This usually leads to erythema, dryness, pruritus and swelling of the skin. In far more serious cases, this can occur as blisters, with either hyper or hypopigmentation of the skin. Once scratched, the areas may turn red and leather-like in character. [2,4]



Image 3 : Eczematous rashes on the inner thigh.

Source: www.truenaturalweightloss.com

 

Excessive Heat and Sweat

Extreme heat and sweat can block sweat glands and their ducts. These eventually lead to inflammation, blister formation, along with appearance of itchy rashes. They are usually in the areas of skin folds and friction, such that on the inner thighs.

Factors like humidity, clothing, physical activity, immature sweat ducts, and use of heavy creams and lotions can contribute to development of such rashes. [4]



Image 4 : A closer look at a heat rash on the inner thigh.

Source: www.skinsight.com

 

Insect Bites

Bites, usually that of common insects such as ants, mosquitoes and bugs, can also produce inner thigh rashes. These usually resolve after a few hours. [2,3]




Image 5 : An erythematous rash was seen after an insect bite at the inner thigh.

Source: www.firstaid.about.com

 

Activities Like Jogging and Cycling

Due to humidity, heat, sweat and friction, activities such as jogging and cycling may also lead to inner thigh rashes. When caused by cycling, these are usually coined as saddle sores.

Either of these activities may lead to lesions characterized as chafed skin, which when neglected, may lead to intense blisters with pus formation known as folliculitis. For more severe cases, these may lead to large, swollen and painful abscesses. [1]



Image 6 : Cycling can also bring about inner thigh rashes, commonly called saddle sores.

Source: www.runladylike.com

 

Shaving

Shaving of one’s thighs with the use of a razor may likely cause the occurrence of razor bumps, seen as erythematous, pruritic spots. These spots, if neglected, may extend and develop into a larger, redder, and more itchy rash. [2]



Image 7 : Shaving of the inner thighs can also lead to occurrence of rashes.

Source: www.exchanges.webmd.com

 

Diaper Dermatitis

Occurring among newborns and infants, diaper use may also bring about rashes termed as diaper or nappy rashes. Presenting as skin irritation, these lesions are usually found when the diaper is filled with urine or feces, and not changed for a long period of time. These are usually described as erythematous rashes extending from the perianal region to the thighs, with either blister, boils, pus, or weeping discharges. [1, 5]


Image 8 : Prolonged exposure of the skin to a full and soiled diaper can lead to the development of diaper rashes extending to the inner thigh.

Source: www.aocd.org

 

Fungal Infections

Otherwise known as jock itch, one of the most common fungal skin infections is usually caused by tinea cruris. Manifestations of which include severe pruritus of skin folds of the thigh, along with erythematous rashes that usually blister and produce pus. The rashes are usually presented as sharply bordered, red patches. [3]



Image 9 : Fungi can also cause skin irritation of the inner thigh.

Source: www.canesten.co.uk

 

Parasitic Infections

A particular infection brought about by a parasite that would cause inner thigh rash is Schistosomiasis. When exposed to water contaminated with a Schistosoma parasite, a skin infection called Swimmer’s itch may ensue. During the illness, the parasite can burrow and penetrate the skin of the inner thigh, producing rashes.

Along with these rashes, systemic manifestations like abdominal pain and diarrhea can characterize this schistosomal infection. These particular infections are usually prevalent in tropical and subtropical regions of the world. [4]



Image 10 : Swimmer’s itch rashes located at the thigh.

Source: www.findmall.com

 

Sexually Transmitted Diseases

Illnesses with sexual transmission, such as syphilis and herpes, can also bring about rashes on the inner thigh. They usually present in the genitals, and may extend to the inner region of the thighs. These may occur in both men and women. [2, 3]



Image 11 : Herpetic skin lesions found along the inner thigh.

Source: www.pic2fly.com

 

Shingles

This disease may present as tender, erythematous skin lesions, experienced alongside with a severe burning sensation. [3]



Image 12 : Skin lesions of patients infected with shingles: up-close.

Source: www.webmd.com

 

Manifestations of a Typical Rash on the Inner Thigh

The following are the usual signs and symptoms present on a patient with inner thigh skin lesions: [1]
  • Pruritus
  • Erythema on the affected area
  • Blister formation
  • Swelling and inflammation
  • Skin irritation
  • Pain and discomfort on ambulation
  • Difficulty of breathing, if already on an anaphylactic state

 

Home Remedies Used In Managing Inner Thigh Rashes

Below are a number of substances and mixtures usually found at one’s home which can be utilized as treatment for rashes of the inner thigh: [1, 3]
  • Olive oil can relieve skin tenderness and decrease its redness.
  • Ice application every few hours, and even cold water washes, can soothe uncomfortable skin lesions.
  • Ascorbic Acid supplements should be taken for better wound healing.
  • Lotion with aloe vera can be applied topical to further alleviate skin irritation.
  • Oatmeals can be used in bathing to relieve the inner thighs of their rashes.
  • Chamomile tea wash may diminish skin irritability.
  • Apple cider vinegar, mixed with honey and taken three times a day, may assist in controlling skin allergies.
  • A concoction of cod liver and vitamin E cream may be applied on the rashes for a quicker cure.
  • Herbs, such as neem and licorice, can help rid of toxins, reducing rashes.

 

Therapeutic Modalities for Inner Thigh Rashes

Medical management of rashes in this particular part of the body would include: [1]

 

Anti-Allergic Medications

Antihistamines can diminish skin eruptions and diminish redness and irritation.

 

Corticosteroids

These medications can decrease the inflammation and pruritic symptoms. These are mostly utilized for chronic eczematous rashes.

 

Moisturizing Products

The skin should always be well hydrated. This can be achieved with the use of moisturizing creams, mainly composed of retinoids, which are derivatives of Vitamin A, and vitamin D. They do not only provide hydration, but also maintain the skin’s nourishment.

 

Immunosuppressants

These drugs can help diminish the severity of rashes, and at the same time, help the integument retain its normal color.

 

Phototherapy

As a skin therapy breakthrough, ultraviolet rays are found to be useful in decreasing the production of dermal cells. Thus, these assist in alleviating this skin nuisance.

 

How to Prevent Inner Thigh Rashes

This skin manifestation is a huge part of the itch-scratch-itch cycle. Thus, it would be wise if this cycle is prevented. The following are ways of doing so: [3]
  • After bathing, completely pat dry the thigh and perineal areas.
  • If one sees beginning manifestations of those rashes, he /she should wash the affected regions two times a day using cold water.
  • Clothes, loose-fitting and made of cotton should be used. One must avoid frequent wearing of tight pants and undergarments.
  • Talcum powder can be used cool the thigh areas and avoid further skin irritation.

References:
  • http://www.emedicalhub.com/inner-thigh-rash-causes-pictures-treatment/
  • http://www.buzzle.com/articles/inner-thigh-rash.html
  • http://www.byebyedoctor.com/inner-thigh-rash-pictures-std-causes-treatment/
  • http://www.livestrong.com/rash-inner-thigh/
  • http://www.mayoclinic.com/health/jock-itch/DS00490

Breastbone Pain (Sternum Pain) - Causes, Diagnosis and Treatment

The breastbone, also known as sternum, is a flat bone situated just beneath the center of the collarbones [1]. It is divided into three parts: the manubrium, the body and the xiphoid process [2]. It functions as the connecting point for the ribs with the help of cartilages. Together with the ribs, the breastbone protects the internal organs in the chest, such as the heart and the lungs [1].



 Picture 1: Location and anatomy of the breastbone

Image source: img.tfd.com



Breastbone pain is defined as a painful feeling in the chest area, characterized by pressure and bruising sensations [1]. This may be felt in the bone itself, underneath the bone, or in the side areas of the breastbone. Sometimes, clicking or cracking sounds can be experienced. This is called popping sternum, which is often accompanied by swelling and tenderness [2].



The pain experienced may be acute or chronic, and may range from mild to severe [1]. Cases with increasing intensity and frequency should be attended by a doctor or a medical professional. However, breastbone pain must not be mistaken for cardiac disorders, as the latter is more serious and needs immediate medical attention.



A heart disorder, such as heart attack, is different from breastbone pain in that the pain in the former is not only felt in the chest area but in the arms, shoulders, and neck as well [3].

 

Breastbone Pain Causes

 

Costochondritis

  • This condition involves pain in the chest wall caused by inflamed joints between cartilages that connect the ribs to the breastbone.
  • Cartilages are essential because it allows the expansion of the rib cage, thereby permitting the lungs to expand freely during breathing. Unlike bones, cartilages are softer and more flexible. These are found in the different joint areas in the body. In the rib cage, the joints that can be found are the costochondral joints (between the ribs and the cartilages), costosternal joints (between the ribs and the breastbone), and the costoclavicular joints (between the collarbones and the breastbone). Inflammation of one or more of these joints causes costochondritis. [4] \
  • The cause of costochondritis is unknown, but medical experts say it may be linked to injury to the ribs or breastbone, physical stress from lifting and carrying heavy objects, or from repeated coughing. [3]

 

Tietze’s Syndrome

  • Similar to costochondritis, the pain in the breastbone experienced in Tietze’s syndrome is also caused by the inflammation of costochondral, costosternal or costoclavicular joints. However, in Tietze’s syndrome, swelling can be experienced. In contrast with costochondritis, only pain and tenderness can be felt in this kind of disease. [4]

 

Bornholm Disease

  • This is another condition similar to costochondritis and Tietze’s syndrome. On the contrary, the cause of this disease is a viral infection, mainly due to the Coxsackie B virus. Aside from breastbone pain, muscle pain is also experienced in this condition. [4]

 

Heartburn

  • Heartburn is a burning sensation felt in the chest or breastbone area. A bitter taste in the mouth often accompanies the burning sensation. This is caused by the reflux of gastric contents into the esophagus, which usually happens after heavy meals, or when lying down immediately after eating. [5]
  • The reflux occurs mainly because of the weakening of the cardiac sphincter, the juncture between the stomach and the esophagus. This juncture closes upon the entry of food into the stomach. The stomach contents leak when the cardiac sphincter does not function properly. [5]


Picture 2: Cardiac sphincter

Image source: biology12-lum.wikispaces.com


This condition may worsen during the following conditions:
  • Smoking
  • Drinking alcohol or caffeinated beverages
  • Eating spicy foods
  • Taking some medications such as aspirin and ibuprofen [5]

Traumas and injuries

  • Traumas and injuries in different bones in the chest can cause breastbone pain. One of the areas that can be affected is the sternoclavicular joint. Injury and dislocation of this joint can cause mild to severe pain in the sternum depending on the severity of the injury. [6]
  • Another cause of breastbone pain is collarbone injury. This injury is quite common and may happen at birth due to accidents or falls. Fixing the collarbone alleviates the breastbone pain. [6]
  • Sternum fractures may also cause breastbone pain. This is mainly caused by physical trauma in the chest area. In worse cases, the sternum may break into pieces. However, breastbone pain caused by sternum fractures and injuries are rare. [6]

 

Muscle Pain

  • Pain in the muscles attaching to the rib cage is also a common cause of breastbone pain. The muscles usually affected are the intercostal muscles and the pectoral muscles. The pain is mainly caused by heavy or deep breathing, causing strain and pain to the muscles. [2]

 

Surgery

  • Surgeries in organs inside the chest cavity, such as open heart surgery (cardiothoracis), may involve the separation of bones in the chest. This causes long term pain, which can be felt even after the surgical wounds are healed. [2]

 

Respiratory Diseases

  • Bronchitis, tracheitis, asthma, tuberculosis and pneumonia are respiratory diseases that may cause breastbone pain due to the difficulty in breathing involved. Sometimes, the pain is not only felt in the breastbone area but on the sides of the chest as well. [2]

 

Psychological Conditions

  • Anxiety and panic attacks may cause palpitations, psychogenic pain and heartburn, which leads to breastbone pain. [2]

 

Other Causes

  • Excessive exercise
  • Hiatal hernia
  • Acute pancreatitis
  • Stomach ulcers
  • Breast cancer
  • Bone cancer [6]

 

Breastbone Pain Treatment


Treatment of breastbone pain depends on the cause or origin of pain.
  • For costochondritis, the pain and inflammation in the joints can be relieved by taking non-steroidal anti-inflammatory drugs or NSAIDs. This should be taken with food or after meals, as this may cause stomach injuries when taken on an empty stomach. This is also contraindicated in people who are on anticoagulant therapy, and in people with stomach ulcers and reflux disorders. When the patient does not respond to NSAIDs, steroids and anesthetics are usually administered.
  • Aside from medications, non-pharmacological treatment can also be done, such as the application of hot and cold compresses, to relieve the pain.
  • For fractures, medical attention is necessary. Doctors diagnose the patient for possible injury through X-rays, MRI, or CT-scan. Fractures must be treated immediately to prevent further damage and injuries to the nearby tissues.
  • For breastbone pain caused by underlying medical conditions and disorders, it is necessary to treat the causative factor. For digestive reflux disorders, medications for heartburn can be taken. These are available over the counter or with prescription. For respiratory disorders, respiratory drugs are given, depending on the type of the disease. Doctors and health professionals can be consulted regarding these medications.
  • Lastly, for anxiety attacks, calming the patient is the first thing to do. The patient’s heart rate must be reverted back to normal. Breathing inside a paper bag may help in alleviating panic and anxiety attacks. [4, 7]

References:

  1. http://sternumpaintreatment.weebly.com/index.html
  2. http://www.healthhype.com/causes-of-breast-bone-pain-sternum.html
  3. http://kidshealth.org/parent/medical/bones/costochondritis.html
  4. http://www.patient.co.uk/health/Costochondritis.htm
  5. http://health.yahoo.net/health/heartburn
  6. http://www.buzzle.com/articles/sternum-pain-causes.html
  7. http://www.md-health.com/Sternum-Pain.html