Neurogenic arthropathy
Neurogenic arthropathy: Excerpt from Handbook of Diseases
Most common in men older than age 40, neurogenic arthropathy (Charcot’s arthropathy) is a progressively degenerative disease of peripheral and axial joints, resulting from impaired sensory innervation. The loss of sensation in the joints causes progressive deterioration, resulting from unrecognized trauma (especially repeated minor episodes) or primary disease, which leads to laxity of supporting ligaments and eventual disintegration of the affected joints.
Causes
In adults, the most common cause of neurogenic arthropathy is diabetes mellitus. Other causes include tabes dorsalis (especially among patients ages 40 to 60), syringomyelia (which progresses to neurogenic arthropathy in about 25% of patients), myelopathy of pernicious anemia, spinal cord trauma, paraplegia, hereditary sensory neuropathy, and Charcot-Marie-Tooth disease. Rarely, amyloidosis, peripheral nerve injury, myelomeningocele (in children), leprosy, or alcoholism causes neurogenic arthropathy.
Frequent intra-articular injections of a corticosteroid have also been linked to neurogenic arthropathy. The analgesic effect of the corticosteroid may mask symptoms and allow continuous damaging stress to accelerate joint destruction.
Signs and symptoms
Neurogenic arthropathy begins insidiously with swelling, warmth, increased mobility, and instability in a single joint or in many joints. It can progress to deformity. The first clue to vertebral neuroarthropathy, which progresses to gross spinal deformity, may be nothing more than a mild, persistent backache. Characteristically, pain is minimal despite obvious deformity.
The specific joint that’s affected varies. Diabetes usually attacks the joints and bones of the feet; tabes dorsalis attacks the large weight-bearing joints, such as the knee, hip, ankle, or lumbar and dorsal vertebrae (Charcot spine); syringomyelia, the shoulder, elbow, or cervical intervertebral joint. Neurogenic arthropathy related to intra-articular injection of a corticosteroid usually develops in the hip or knee joint.
Diagnosis
A patient history of painless joint deformity and underlying primary disease suggests neurogenic arthropathy. The physical examination may reveal bone fragmentation in advanced disease. X-rays help confirm the diagnosis and help assess the severity of joint damage.
In the early stage of the disease, soft-tissue swelling or effusion may be the only overt effect; in the advanced stage, articular fracture, subluxation, erosion of articular cartilage, periosteal new bone formation, and excessive growth of marginal loose bodies (osteophytosis) or resorption may be seen.
Other diagnostic measures include:
❑ vertebral examination:narrowing of disk spaces, deterioration of vertebrae, and osteophyte formation, leading to ankylosis and deforming kyphoscoliosis
❑ synovial biopsy: bony fragments and bits of calcified cartilage.
Treatment
Effective management relieves associated pain with an analgesic and immobilization, using crutches, splints, braces, and restriction of weight bearing.
In patients with severe disease, surgery may include arthrodesis or, in those with severe diabetic neuropathy, amputation. However, surgery risks further damage through nonunion and infection.
Special considerations
❑ Assess the pattern of pain, and monitor the effectiveness of analgesis.
❑ Check sensory perception, range of motion, alignment, joint swelling, and the status of underlying disease.
❑ Teach the patient joint protection techniques. Also, advise him to avoid physically stressful actions that may cause pathologic fractures, and encourage him to take safety precautions, such as removing throw rugs and clutter that may cause falls.
❑ Advise the patient to report severe joint pain, swelling, or instability.
CLINICAL TIP: Warm compresses may be applied to relieve local pain and tenderness.
❑ Teach the patient the proper technique for using crutches or other orthopedic devices. Stress the importance of proper fitting and regular professional readjustment of such devices and the importance of good skin care. Warn that impaired sensation might allow damage from these aids without discomfort.
❑ Emphasize the need to continue regular treatment of the underlying disease.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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