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Differential Diagnosis of Neuropathic Ulceration

- Differential Diagnosis:
    - vascular lesions:
         - location of ulcerations/lesions may be helpful in determining etiology of the lesions;
         - gangrene secondary to ischemia/arterial insufficiency will usually start at the most distal part of the extremity;
         - neuropathic lesions tend to occur on wt bearing areas and rarely become gangrenous unless there is associated infection or arterial insufficiency;
    - osteomyelitis
          - neuropathic ulcerations may resemble the lesions found in osteomyelitis in that foot appears swollen with overlying erythema and warmth;
          - history, exam, laboratory data, and radiographs can all help to distinguish between Charcot joint and infection;
          - exam:
                - w/ neuropathic foot, pt may present with a hot swollen erythematous, but painless foot;
                - pt w/ dense neuropathy will have marked muscle wasting which should not be confused with ischemia;
                - if ulceration is present, it will be of the mal perforant type vs the ischemic type;
                - an ulcer that leads directly down to bone (along w/ radiographic osteolytic changes) is more indicative of infection;
          - labs: w/ Charcot foot
                - glucose under control and the HA1c is normal;
                - normal ESR
          - radiographs:
                - bone/gallium scan or indium scan may help to r/o osteomyelitis, but these are usually not necessary;
                - plain radiographs should be scrutinized for osteolysis which is usually not present in Charcot joints (and is more indicative of osteomyelitis);
    - syphilis:
         - neuropathetic phase of diabetes is a specific degeneration closely resembling neuropathic changes of late syphilis, & like diabetic gangrene, it has a prediliction for the foot;
         - changes are essentially caused by the destruction of the posterior horn of the spinal cord;
         - most drastic results of the trophic changes are complete collapse and distortion of the tarsometatarsal articulation;
                - this may occur as a Charcot type of destruction