Charcot arthropathy — Rapid | Doctor’s Passport

Synopsis

Treat the hot swollen neuropathic foot as active Charcot neuroarthropathy until excluded, distinguish it from infection without false reassurance, institute immediate knee-high immobilisation and offloading, and prevent collapse, ulceration and amputation through multidisciplinary care.

Suspect active Charcot neuroarthropathy when a person with neuropathy develops unilateral foot warmth, swelling, redness or shape change, often after minor or unremembered trauma and with surprisingly little pain.
First-line action precedes imaging: make the patient non-weight-bearing, immobilise in a knee-high device and refer to the multidisciplinary foot-care service within one working day.
Assess infection and perfusion at the same encounter; Charcot disease, ulcer infection, osteomyelitis and peripheral arterial disease can coexist rather than being mutually exclusive.
First-line imaging is weight-bearing foot and ankle radiography when safe, but normal early films do not exclude active disease; obtain MRI when suspicion remains and radiographs are normal or infection is uncertain.
A non-removable knee-high total-contact cast is the reference offloading method when trained services, skin and perfusion allow; use a safe removable knee-high alternative when monitoring or contraindications require it.
Continue immobilisation and offloading until clinical inflammation has resolved and temperature and imaging are stable under specialist criteria, then transition gradually into custom footwear or Charcot restraint orthotic support.
Do not use antibiotics for warmth alone, and do not use bisphosphonates routinely as a substitute for offloading; treat proven infection with deep sampling and source control.
Consider reconstruction for instability, non-plantigrade deformity or recurrent ulceration that cannot be accommodated, after active inflammation, infection and perfusion have been addressed.

Key red flags

A newly hot red swollen foot with diabetes or other neuropathy requires immediate immobilisation and non-weight-bearing even if pain is mild and the first radiograph is normal.

Ulcer probing to bone, purulence, spreading erythema, systemic illness or raised sepsis risk suggests infection or osteomyelitis that may coexist with Charcot change.

Crepitus, bullae, skin necrosis, gas, disproportionate pain or shock requires emergency debridement for necrotising or deep infection.

Gangrene, rest pain, cool tissue, absent pulses or rapidly progressive loss requires immediate vascular and surgical limb-salvage assessment.

Tight casting, new numbness, pressure pain, colour change or reduced perfusion requires urgent device removal and skin and neurovascular review.

Investigation priorities

First-line bilateral foot and systemic assessmentFirst stepFirst line

Identify active inflammation, neuropathy, ulcer infection, sepsis and perfusion threat before imaging.

First-line weight-bearing foot and ankle radiographs when safeFirst line

Detect fracture, subluxation, fragmentation, collapse, gas and bony destruction and provide an alignment baseline.

Management branches

ImmediateOffload before confirmation

A neuropathic foot becomes unilaterally hot, swollen, red or newly deformed.

Stop weight-bearing, provide safe transport and immobilise in a knee-high device that protects current alignment and skin.
Inspect for ulcer and spreading infection and assess systemic physiology, glucose, sensation, pulses and the other foot.
Obtain weight-bearing radiographs only when safe and arrange MRI when films are normal but suspicion remains.
Refer to the multidisciplinary foot-care service within one working day, immediately to acute care for limb- or life-threatening disease.

Key medicines

Flucloxacillin for selected mild diabetic-foot infectionWhen clinical infection is mild and oral treatment is appropriate, give flucloxacillin 500 mg to 1 g orally four times daily for 7 days, then review response and microbiology; the 1 g four-times-daily dose is off label.Antibiotics are not indicated for sterile Charcot warmth; admit severe infection, check allergy, liver and renal function and interactions, and obtain drainage, deep samples and vascular care when required.

VTE prophylaxis during immobilisation when risk outweighs bleedingUse the local prophylactic low-molecular-weight heparin or fondaparinux regimen after weight, renal function, pregnancy, platelet and bleeding review, following NICE NG89 and considering stopping when lower-limb immobilisation continues beyond 42 days.Do not prescribe automatically; review active ulcer bleeding, renal impairment, other antithrombotics, falls and procedures, and give urgent advice for bleeding, calf swelling or breathlessness.

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