Milwaukee shoulder syndrome affecting the elbow



Illustration 1.

The patient, an 87-year-old woman, was referred to the rheumatology department for pain in the shoulders and left elbow, associated with increased markers of inflammation (C-reactive protein level 200 mg/liter). Active mobility of these joints had been severely limited for 4 months, leading to progressive incapacity of the arms. On physical examination, loss of the normal rounded contour of both shoulder muscles was apparent, with a palpable depression in the upper humeral area of the right shoulder (A). All of the synovial fluid cultures and blood cultures were sterile. Results of immunologic tests were negative for rheumatoid factor and anti–citrullinated peptide antibody. Radiographs showed complete bilateral osteolysis of both the humeral head and the glenoid cavity of the scapula (B) and severe destruction of the radial head of the left elbow (C), with the presence of osteochondral loose bodies. Neuropathic arthropathy was initially suspected, but careful neurologic examination, spine magnetic resonance imaging, syphilis serology tests, and electromyography did not reveal an underlying neurologic disorder such as syringomyelia (1). Posttraumatic osteolysis of the shoulder was also possible, but seemed unlikely because there had been no acute traumatic event and there was inflammatory oligoarticular involvement. Shoulder arthrocentesis yielded a hemorrhagic inflammatory fluid with no crystals seen on polarized microscopy. Alizarin red staining of the synovial fluid revealed hydroxyapatite crystals. The diagnosis of bilateral Milwaukee shoulder also affecting the left elbow was proposed, and the patient was treated successfully with a 4-week regimen of oral corticosteroids. This rare destructive arthropathy described in 1981 (2) occurs predominantly in elderly women, usually affects a single joint, and is characterized by intraarticular or periarticular hydroxyapatite crystals and rapid destruction of the rotator cuff and the glenohumeral joint (3). Calcium pyrophosphate or apatite crystal deposition involving other peripheral joints is sometimes described (1, 2).