Charcot knee and avulsion fracture of the lesser trochanter in a patient with type 1 diabetes — ASN Events
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Charcot knee and avulsion fracture of the lesser trochanter in a patient with type 1 diabetes (#360)

Sheila Cook 1 , Franziska Charteris-de Looze 1 , Sandya Jalapu 1 , Alan Loch 1
  1. Toowoomba Health Service, Toowoomba, QLD, Australia

We describe the case of a 32 year old woman with poorly controlled Type 1 Diabetes (16 year duration, HbA1c 11.6%), complicated by severe lower limb polyneuropathy, gastroparesis, and microalbuminuria.

She presented to our hospital with a 2 week history of mildly painful swelling of her left knee following minimal trauma. 

Plain films revealed a comminuted fracture of the left tibial plateau, with Charcot neuroarthropathy confirmed on MRI.  Arthroplasty was performed to stabilize the joint.  Bone biopsy confirmed osteonecrosis, with no evidence of malignancy or infection.

Her metabolic work up demonstrated normal Vitamin D status and central hypogonadism:  PTH 1.8pmol/L, 25-hydroxy-Vitamin D 69nmol/L), ALP 190, P1NP 100ug/L (15-95), TSH 1.4, FT4 16, Oestradiol <30 pmol/L, FSH 3.7 U/L, LH 3.7 U/L, Prolactin 235.  Coeliac antibodies and myeloma screening tests were negative.

Management included immobilization, intensification of glycaemic control, oestrogen replacement, Vitamin D and calcium supplementation.

Three months after the original presentation, the patient suffered another minimal trauma fracture, now resulting in an avulsion fracture of the left lesser trochanter.  This was treated conservatively with immobilization.  Bone scan revealed increased uptake at the sites of known fractures. There was no suggestion of bony metastases.

Charcot osteoarthropathy of the knee is a very rare complication of poorly controlled diabetes, with only 15 case reports published in the literature (1). It occurs as a result of severe sensorimotor and autonomic neuropathy contributing to dysregulated periosteal blood supply, inflammation and increased osteoclastic activity, leading bone resorption and fracture (2).  Typically, fracture causes painless swelling.

Avulsion fracture of the lesser trochanter is normally seen in younger active individuals, but has been rarely described in older people due to malignancy, and chronic diseases that increase the likelihood of osteoporosis (3).  There are two published case reports describing patients with type 1 diabetes.

This case describes two very rare complications of diabetes in the same patient. 

  1. Ulrich I, van Netten J, Droste C, Postema K, Meiners T, Wetz HH. Diabetic Charcot Neuroarthropathy of the Knee: Conservative Treatment Options as Alternatives to Surgery Case Reports of Three Patients. Diabetes Care 2014;37:e129–e130
  2. Babazadeh S, Stoney JD, Lim K, Choong PFM, Arthroplasty of a Charcot knee, Orthopedic Reviews 2010; volume 2:e17, p65-9
  3. Rouvillain JL et al. Isolated lesser trochanter fracture in adults: An early indicator of tumour infiltration. Orthopaedics and Traumatology 2011; 97: 217-220