---

📋 Orthopaedic Case Sheet — Swelling Over the Elbow Joint

---

Clinical Images

---

SECTION 1: HISTORY (Chief Complaints & HPI)

Biodata

Chief Complaint

History of Presenting Illness — Ask in SOCRATES Format

• Posterior (olecranon region) → Bursitis, gout tophi, rheumatoid nodule
• Lateral → Lateral epicondyle swelling, loose body
• Medial → Medial epicondyle, cubital tunnel ganglion
• Diffuse / whole joint → Septic arthritis, rheumatoid, haemarthrosis, fracture

• Sudden after trauma → Fracture, haemarthrosis, traumatic bursitis
• Rapid (hours) with fever → Septic bursitis / septic arthritis ⚠️
• Gradual, progressive → Rheumatoid arthritis, chronic bursitis, gout, OA, tumour
• Recurrent episodes → Gout (most common cause of recurrent acute joint swelling)

• Soft, fluctuant → Bursitis (fluid), effusion, ganglion
• Firm/hard → Tophus, rheumatoid nodule, osteochondroma
• Progressive enlargement + hard → Soft tissue tumour / bone tumour ⚠️ Red flag

• Pain: Constant vs activity-related; severity (VAS 1–10); radiation
• Redness / warmth → Septic, crystal arthropathy
• Morning stiffness >1 hour → Rheumatoid arthritis
• Stiffness worsening with activity → Osteoarthritis
• Fever, chills → Septic process ⚠️
• Restricted movement → Fracture, septic arthritis, severe effusion
• Numbness/tingling in ring & little fingers → Ulnar nerve involvement (cubital tunnel syndrome)
• Locking / clicking → Loose body (osteochondritis dissecans)
• Skin wounds, abrasions over the swelling → Portal of entry for septic bursitis

• Worse with extension pressure (leaning on elbow) → Bursitis
• Worse with wrist extension against resistance → Lateral epicondylitis (tennis elbow)
• Worse with wrist flexion → Medial epicondylitis (golfer's elbow)

Past History

• Previous similar episodes (recurrent gout, RA flares)
• Prior trauma to the same elbow
• Previous surgery or aspiration of the swelling
• Tuberculosis (TB) — ask specifically for septic/monoarthritis differential

Medical History

• Gout / hyperuricaemia
• Rheumatoid arthritis, SLE, psoriasis
• Diabetes mellitus ⚠️ (risk factor for septic bursitis)
• Chronic renal failure, dialysis patients (gout + RA associations)
• Alcohol abuse (gout, septic risk)
• Haemophilia (haemarthrosis)
• Malignancy (metastatic swelling, immunocompromise)
• Immunosuppression (steroid use, chemotherapy)

Drug History

• Corticosteroids → predispose to infection, tendon rupture
• Fluoroquinolones → tendinopathy
• Diuretics → precipitate gout
• Allopurinol / urate-lowering therapy — already on treatment?
• NSAIDs — on regular use?

Family History

• Gout (strong hereditary component)
• Rheumatoid arthritis
• Haemophilia

Occupational & Social History

• ⚠️ Key question: Repetitive elbow trauma at work (gardening, plumbing, mining, manual labour) → olecranon bursitis
• Sports (tennis, golf, throwing sports)
• Alcohol intake (gout risk)

---

SECTION 2: PHYSICAL EXAMINATION

General Examination

• Build, nutrition, pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema
• Temperature (fever → septic process)
• Other joint involvement (polyarthritis → RA, gout, psoriatic)
• Skin: tophi elsewhere (ear pinnae, finger joints), rheumatoid nodules, psoriatic plaques, cellulitis

---

LOCAL EXAMINATION — Elbow

LOOK (Inspection)

FEEL (Palpation)

MOVE (Range of Motion)

⚠️ Key point: In olecranon bursitis, passive ROM at the elbow is relatively preserved and painless, except at full flexion (which compresses the inflamed bursa). This distinguishes bursitis from septic arthritis where all movements are painful.

Special Tests

Neurovascular Examination

• Radial pulse (distal)
• Median nerve: Thenar wasting, grip strength, palmar sensation
• Ulnar nerve: Interossei, hypothenar, ring/little finger sensation
• Radial nerve: Wrist/finger extension, dorsal hand sensation

---

SECTION 3: DIFFERENTIAL DIAGNOSIS OF ELBOW SWELLING

---

SECTION 4: INVESTIGATIONS

Bedside / Bursal Fluid Aspiration (Most Important!)

Aspirate if septic bursitis is suspected — diagnostic AND therapeutic

Blood Investigations

• CBC with differential (leucocytosis in septic)
• ESR, CRP (acute phase reactants)
• Serum uric acid (gout — but may be normal during acute attack!)
• Blood culture (if fever/systemic sepsis)
• RF, anti-CCP (rheumatoid arthritis)
• HLA-B27 (spondyloarthropathy)
• Serum calcium, ALP (metabolic bone)
• Blood glucose (if diabetic)

Imaging

• X-ray elbow (AP + lateral): Bony erosions (RA, gout), calcifications, fractures, osteophytes (OA), joint space narrowing, soft tissue shadow
• Ultrasound: Best for bursal fluid, extent, guided aspiration; detect lipoma, ganglion
• MRI: Soft tissue tumour characterisation, ligament/tendon integrity, marrow involvement
• CT scan: Bony detail, suspected tumour extent

---

SECTION 5: TREATMENT PRINCIPLES

Non-Infective Olecranon Bursitis

• Rest, compression bandage, ice packs
• NSAIDs (ibuprofen, diclofenac)
• Avoid inciting activity (no leaning on elbow)
• Aspiration (therapeutic) if large and symptomatic
• Intra-bursal corticosteroid injection (only after infection excluded)

Septic Bursitis

• Aspiration — drain all fluid; send for culture
• Antibiotics: Cover Staphylococcus + Streptococcus + MRSA
  • Outpatient: TMP-SMX DS BD or Doxycycline 100 mg BD × 10–14 days
  • Inpatient: IV Vancomycin 15–20 mg/kg ± piperacillin/tazobactam
• Follow up at 24–48 hours to check culture results and response
• Bursectomy if refractory to aspiration + antibiotics
• ⚠️ Indications for admission: Systemic sepsis, extensive cellulitis, immunocompromise, failure of outpatient treatment, suspected joint involvement

Gout

• Acute: NSAIDs, colchicine, corticosteroids
• Chronic: Allopurinol (urate-lowering), lifestyle modification, hydration

Rheumatoid Arthritis

• DMARDs (methotrexate first-line), biologics; orthopaedic referral for synovectomy/reconstruction

---

⭐ IMPORTANT POINTS TO REMEMBER (Exam Keys)

1. Olecranon bursitis is the most common cause of posterior elbow swelling — the olecranon bursa is the only bursa of the elbow joint and is most vulnerable to isolated pathology.
2. ⚠️ Hot swollen joint = septic arthritis until proven otherwise — this is a surgical emergency requiring urgent aspiration.
3. Bursitis vs Septic Arthritis distinction:
   • Bursitis: ROM relatively preserved, pain only at full flexion (bursa compression)
   • Septic arthritis: ALL movements painful, generalised joint swelling, fever
4. Occupational history is critical — repetitive elbow trauma (gardening, plumbing, mining) is the most common cause of olecranon bursitis.
5. Bursal fluid WBC cutoffs: <1,000 → traumatic/non-septic; >3,000 (mean ~54,000) → septic; 1,000–6,000 → crystal-induced.
6. Serum uric acid can be NORMAL during an acute gout attack — do not rule out gout based on a normal uric acid level.
7. Skin integrity over the bursa must be checked — abrasions/lacerations are the portal of entry for septic bursitis.
8. Crystal types: Gout = needle-shaped, negatively birefringent monosodium urate; CPPD = rhomboid, positively birefringent calcium pyrophosphate.
9. Red flags for malignancy: Progressive painless firm swelling >5 cm, fixed to deep structures, night pain, skin not pinchable → urgent MRI + biopsy.
10. Always examine joint above (shoulder) and below (wrist) to complete the elbow examination — cubital tunnel/ulnar nerve must be assessed with every elbow case.
11. Staphylococcus aureus accounts for the majority of septic bursitis infections (including increasing MRSA prevalence — adjust antibiotics per local sensitivities).
12. Rheumatoid nodules are firm, non-tender, found at pressure points (olecranon, sacrum) — can mimic bursitis clinically.

---