Charcot (Neuropathic) Joint of the Elbow

A grossly swollen, unstable elbow with marked radiographic destruction that is relatively painless - destruction out of proportion to the symptoms - is the classic picture of a Charcot, or neuropathic, joint, a progressive destructive arthropathy of an insensate joint, in which the loss of protective sensation and proprioception leads to repeated unperceived microtrauma and joint destruction with fragmentation and debris. At the elbow, and the shoulder, the classic underlying cause is syringomyelia, so my key investigation is MRI of the cervical spine to detect a syrinx, along with examination for the dissociated, pain and temperature, sensory loss that syringomyelia causes; other upper-limb sensory neuropathies can also be responsible. Before I attribute the destruction to a neuropathic process, however, I must exclude the crucial mimics - infection, that is septic arthritis or osteomyelitis, and tumour - because the markedly destructive, sometimes expansile, mass-like appearance can mimic malignancy; so I would obtain appropriate radiographs and CT of the elbow, inflammatory markers, and a biopsy where there is genuine uncertainty. Management is largely supportive: protecting the joint with bracing, splinting and activity modification, and treating the underlying cause, for example neurosurgical decompression of a syrinx. Surgery on the joint itself - arthrodesis or arthroplasty - is limited and high-risk in a neuropathic, insensate joint, with high failure and complication rates, and is reserved for selected severe cases within a multidisciplinary approach that includes neurosurgery.