Case 3 TB Arthritis Ankle


Case 3

TB Arthritis Ankle 
Introduction , Permission to ask questions and examine. Tell patient to remind him if the patient is not comfortable during the examination.

Two Relevant Questions

What happened ?                                            Pain and swelling  elsewhere on body ?


Shoe Wears – Worn outerside of sole
Gait – Limping
Alignment of Ankle /foot and toes – Normal
Attitude of Ankle  - no any particular 
No LLD
Look ankle / foot / leg  from Front , Side and Back on standing position
Skin erythematous and oedematous around ankle ,
Skin on dorsum of foot normal , normal medial arch from side and no too many toes from back
Calf muscle – wasted
          Ask patient to lie with feet out of bed – see the sole of feet

Feel  - Always first superficially then deep for bony palpation .
                                                Feel Temperature at Contralateral Ankle / Affected Ankle
Superficial then Deep Palpation
Tibia , Medial Malleolus , First metatrasal ,phalanges, other metatarsal bones, heel , lateral mallolus and along fibula
Ankle joint at last
Fluctuation at ankle joint

Palpate Popliteal and inguinal lymph nodes
Movement –                            Dorsiflexion , Plantarflexion of ankle , toes , and knee if possible
LLD – not there
Ligamentous Instability –
                                                Anterior and Posterior Drawer test
                                                Inversion/ Eversion stress test

Neurovascular Assessment
                                                Senstation – Dorsum of foot , first toe web space , sole
                                                Power of muscles – TA ,TP , Extensor of toes , Gastrosoleus
                                                Reflexes if time allows 

                                               

D/D
Arthritis of Ankle
Inflammatory Arthrtits
Infective Arthrits
Post traumatic Arthritis
Charcot Neuroapthy if there is DM
         Tensosynovitis of Flexor Tendons / TP


Investigations
Blood
CBC , ESR ,
Additionally to diagnose systemic illness
                        RBS, RA Factor
                        Urine R/E

Xray- Ankle – AP , Lateral
MRI
           
Treatment
            General ATT
            Splint in a neutral position
            Non weight bearing in a caliper

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