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



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