Case 21 Tophus

Case 21

Tophus

 What happened ?                                           Swelling  elsewhere on body ?

Shoe Wears – Worn outerside of sole

Alignment of Great toe

Attitude of Ankle / Lower extremity  - no any particular 

Look foot from Front , Side and Back on standing position

                                                Swelling over Ist MTP joint around 3 ,3 cm

Skin over medial border of Ist MT head –red , swollen ,shiny

Medial Arch maintained

and no too many toes from back

Gait –                                      limping 

 See hand , elbow , ear pinna , ankle 

Ask patient to sit and feet out of bed – see the sole of feet

Feel  -                                      Temperature increased

Swelling – site , size, surface , consistency , border , mobile , tender, pulsation , skin pinchable or not , transillumination

Always first superficially then deep for bony palpation .

Heel ,malleoli , other metarasal bones on feet ,small toes then first metatarsal ,Great toe

Sessamoid complex, medial eminence , First Metatarsophalnageal joint at last – non tender ,

Lymph node

Movement –                            toe – 2 planes

Always not to miss comment on LLD – DEVELOP A HABBIT TO THINK ON THIS

Ligamentous Instability          check if it is there

Digital Senstion , Capillary refill to say that the great toe is well perfused and has intact sensory innervation .

Ankle and Subtalar Motion

DPA / PTA

Impression – Hard lesion overlying Ist MTP Joint possibly     Gouty Tophus ,

Soft tissue tumor

                        Cystic lesion overlying Ist MTP joint possibly             Cold Abscess

                                                                                                Haematoma – Trauma /Blood Dyscriasis

            Investigation

USG

Aspiration of fluid and study under Microscopy

Negatively Birefringent Crystals under polarized light is suggestive of Gouty Tohpus