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<v ->Okay, guys, the first case I'm gonna show you, okay,

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is patient

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with swelling

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of the foot

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without pain.

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Only swelling, okay.

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It's a 68-year-old male.

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And I'm gonna scroll the image here.

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As we can see,

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the T2 with fat saturation.

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What can we see here?

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There is some OA here.

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First metatarsophalangeal joint.

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We see a lot of bone marrow edema.

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Diathesis of the second, third,

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and fourth meta,

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and the base of the fifth.

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Also,

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the cuneiforms,

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they have also edema here,

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and the cuboid bone.

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And we have a articular process here.

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Something is going on at the Chopart joint.

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We have irregularities of the cortical bone,

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osteophytes,

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cysts.

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Okay, and we have soft tissue subcutaneous edema here.

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Let's take a look

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at the sagittal.

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The sagittal T2

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is showing osteophytes,

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signs of OA on multiple joints,

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all the Chopart articulation,

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Chopart joint.

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And let's take a look, we have some synovial fluid here.

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And let's take a look at the axials,

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starting with the T2 and the T1.

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The T1, we can see

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that the second metatarsal

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has more edema,

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as it has a low signal,

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lower than the other meta here.

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See the complete disorganization of the Chopart joint.

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We can also appreciate the muscle.

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We don't have a lot of muscle here.

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We have typical muscle atrophy with fat atrophy.

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So we are talking about a chronic atrophy

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of all the forefoot and middle foot muscle bellies.

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And how it is disappearing at T2 weighted image.

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We don't actually see a lot

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of muscle edema

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because of all this atrophy.

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So we'll probably be talking

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about a chronic denervation

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of the muscles with no activity.

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So when you look at this kind of findings,

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you have multiple findings.

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You have signs of insufficiency or stress fractures.

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Now we can see the bone marrow edema here typically.

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We have osteoarthritis

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of all the Chopart joints.

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And we have a denervation.

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So we're probably talking about a diabetic foot, okay.

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And so we go and take a better look

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at the clinical history,

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and you see this patient has chronic diabetes.

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So we make this diagnosis of a neuropathic joint.

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It's called the Charcot foot or the Charcot neuropathy.

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And why this happens,

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why this patient has no pain?

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Because the patients with polyneuropathy,

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diabetic polyneuropathy,

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they lost the sensibility, the sensitivity

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of the foot,

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and they don't protect the foot anymore.

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So that's why you have multiple stress fractures

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in multiple bones.

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You develop a lot of osteoarthrosis.

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And we can see together with the loss

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of sensitivity

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we have atrophy, okay.

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So looking at the post-contrast,

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we can see we have enhancement.

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We have enhancement of the bones.

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We have also soft tissue enhancement.

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And the mainly differential diagnosis

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here is with infection.

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And how one can differentiate if you have infection

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or if you have an early polyneuropathy

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alone?

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Many times we will have both.

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We will have a patient with a chronic neuropathy.

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They lost the sensitivity.

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So they don't feel their injuries.

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So as they do stress fractures,

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as they develop osteoarthrosis,

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they will develop ulcers, and they don't feel it.

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So usually when you have infection in diabetic foot,

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you already have a Charcot joint or a polyneuropathy.

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You already have.

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So how can you tell that if there is no infection at all?

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Okay, so I would look, recommend you looking for the,

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we have some findings that are,

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have a high positive predictive value for infection.

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And when those signs are present, then you can tell,

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you can tell that you have a infection.

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And what are the signs?

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The first one, a very high positive predictive value,

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abscess, we don't see any abscess in this case here.

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A second one, a fistula.

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And actually we don't see also the fistula here.

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And those are the most important ones.

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Don show it in the presentation.

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The ghost sign.

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The ghost sign is when you lose the visualization

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of the cortical bone.

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So then you are dealing with osteomyelitis.

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In the Charcot joint, we can see in this exam here

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that although we have a disorganization,

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we did not lose the contour of the cortical bone.

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So we have in this case a lot of neuropathic joint,

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but we don't, probably don't have infection.

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If we look for the other foot,

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the findings, they are similar.

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We have similar findings

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because polyneuropathy is bilateral, is a systemic thing.

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So here is the other foot.

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We don't have OA on the hallucis,

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but we have all the Chopart joint with OA here.

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And also we have stress

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or insufficiency fracture.

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Also, we have the atrophy,

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not as much as the other,

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we have some muscles here

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that are not compromised by the atrophy,

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but we have chronic atrophy here.

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Don, so this was the case.

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If you wanna do some comments about this case.

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<v ->No, I think it again points out the difficulty

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in diabetes in particular, because of the occurrence

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both of neuropathic disease and of infection.

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And although, as you said, there are some very good signs,

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we struggle sometimes in our own clinical material.

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One other point I'd make about neuropathic disease

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and the diabetic foot.

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In the midfoot, it is often rapidly developing

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with a lot of bone fragmentation.

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When you look at the forefoot,

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particularly at the metatarsal phalangeal joints,

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it tends to be slower and more bone resorption

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than there is bone fragmentation.

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So the morphology's a little bit different.

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But no, I think it can be difficult.

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And I think you pointed out some of the important things

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to look for.

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<v ->Okay, and this is the ankle of the same patient

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showing the flat foot deformity

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and the insufficiency fracture.

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We can visualize the fracture here of the cuboid.

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And also with the atrophy extending

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to the midfoot in.