P188 Sudeck's atrophy

Published Date: 19th July 2016

Publication Authors: Keigan S, Mohsin N

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Case history

A 49-year-old woman with Type 2 diabetes for 17 years, diabetic retinopathy and sensory neuropathy presented with a 2week history of left forefoot, plantar ulcer and cellulitis. Peripheral pulses were palpable; clinically and radiologically there was no osteomyelitis. Wound swab revealed methicillin resistant Staphyloccus aureus (MRSA), Group B Streptococcus and anaerobes. She was initially treated with intravenous (IV) vancomycin and metronidazole for 10 days and then with IV teicoplanin for 4 weeks. The antibiotics were then changed to oral doxycycline and fuscidic acid for 3 weeks. The ulcer healed in 10 weeks, but the patient developed left forefoot oedema, erythema and pain. A repeat X-ray of the left foot revealed patchy bone demineralisation, significantly different from the initial X-ray. MRI of the left foot showed subcutaneous soft tissue thickening with marrow oedema of the first metatarsal, most pronounced in the subarticular region. There was enhancement of these areas with IV contrast. A transverse fracture line extending through the navicular was noted. The clinical features of pain, swelling, erythema (after the ulcer healed) and radiological findings were consistent with complex regional pain syndrome or Sudeck's atrophy. The patient was provided analgesia, air-cast walker and referred for passive ankle physiotherapy. The oedema, erythema and tenderness settled in about 6 weeks.

Conclusion 

This case highlights the importance of considering Sudeck's atrophy in patients with treated diabetes foot infections in the presence of unexplained pain, erythema, oedema and the typical radiological change of patchy demineralisation.

Srinivas-Shankar, U; Elliot, C; Majid, N; Narayanan, R; Keigan, S; Chiran, P; Mohsin, N. (2014).  P188 Sudeck's atrophy: An uncommon complication of diabetes foot infection . Diabetic Medicine. 31 (Supplement S1), 83-84

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