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Illustration 1. The patient, a 35-year old woman with a 12-year history of rheumatoid arthritis (RA), presented with refractory polyarthritis. She had been treated with methotrexate, sulfasalazine, hydroxychloroquine, prednisolone, and nonsteroidal antiinflammatory drugs. Physical examination revealed swelling and tenderness in several proximal interphalangeal joints of the hands and wrists, the left elbow, and the right knee. Laboratory evaluations showed a rheumatoid factor titer of 1,881.4 units/ml and an anti–cyclic citrullinated peptide antibody titer of 158.0 units/ml. The erythrocyte sedimentation rate was 73 mm/hour and the C-reactive protein level was 3.31 mg/dl. Multiple erosions and marked joint space narrowing were found on the plain radiographs of inflamed joints. Of note, characteristic findings of elbow RA, joint space narrowing and marginal erosions on the humeroulnar and radiocapitellar joints, erosions on the olecranon, and cystic changes in the olecranon and the lateral condyle of the humerus (1) were shown on plain radiographs of the left elbow (left). In addition, there was a large hole in the olecranon fossa of the left elbow (left), which was more clearly shown on 3-dimensional computed tomography scan (right). The hole was considered to be supratrochlear foramen, rather than an erosive change caused by RA. Supratrochlear foramen has been reported to be quite common and is formed by the absorption and perforation of a thin bony plate separating the olecranon and the coronoid fossa of the humerus (2). A treatment regimen of golimumab and methotrexate was initiated in this patient, which markedly reduced joint inflammation, pain, swelling, and tenderness.

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  • 1
    Lehtinen JT, Kaarela K, Ikavalko M, Kauppi MJ, Belt EA, Kuusela PP, et al. Incidence of elbow involvement in rheumatoid arthritis: a 15 year endpoint study. J Rheumatol 2001; 28: 704.
  • 2
    Nayak SR, Das S, Krishnamurthy A, Prabhu LV, Potu BK. Supratrochlear foramen of the humerus: an anatomico-radiological study with clinical implications. Ups J Med Sci 2009; 114: 904.