Shoulder joint rupture and pseudothrombosis in rheumatoid arthritis

SUMMARY A patient with rheumatoid arthritis developed sudden unilateral oedema of the right arm resembling vascular obstruction and was shown to have a ruptured shoulder joint. A 64-year-old man with a 1 4-year history of seroposi-tive, erosive and nodular rheumatoid arthritis was admitted for assessment. Previous therapy had con-sisted only of intermittent aspirin. He had a 5-year history of emphysema and chronic airways limitation and had been an alcoholic. Clinical examination showed a man with widespread active synovitis, joint deformities, and multiple nodules. Radiographs L showed erosive changes in all affected joints, includ-ing shoulders and elbows, with extensive joint des-truction in some. After physiotherapy he was noted to develop sud-den painless swelling of his right arm. Examination '-revealed an oedematous arm with normal pulses and no venous engorgement (Fig. 1). A Doppler study of the brachial and subclavian veins was normal. An arthrogram was performed on the right shoulder by the lateral approach (Fig. 2). Distal extravasation of dye from the Joint was demonstrated medially, pos-teriorly, and inferiorly. The swelling subsided with elevation of the arm, but pitting oedema was still F present for 8 days afterwards. The shoulder move-ments were restored to near normal on conventional therapy 3 weeks after the incident. Discussion Acute rupture of the capsule of the knee joint resembling deep calf vein thrombosis has been well described. An adult with chronic synovial rupture of the shoulder joint producing an inflammatory cys