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🦴 Orthopaedics Case Sheet: Swelling Over Left Elbow Joint

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PART I — CASE SHEET FORMAT

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SECTION 1: PATIENT IDENTIFICATION

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SECTION 2: CHIEF COMPLAINT

• ± Pain
• ± Restriction of movement
• ± Redness / warmth

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SECTION 3: HISTORY OF PRESENTING ILLNESS

• Onset — Sudden (trauma/infection) or gradual (chronic/inflammatory)?
• Duration — Acute (<2 wks) vs. chronic (>2 wks)
• Progression — Increasing / static / decreasing in size
• Site — Posterior (olecranon bursa, triceps), anterior (cubital fossa), medial, lateral
• Character of swelling — Soft/fluctuant (bursitis, effusion), firm (lipoma, ganglion), hard (bony, osteochondroma)
• Pain — Present or absent; if present: severity, character (aching, throbbing), aggravating/relieving factors
• H/o trauma — Specific blow, fall on outstretched hand, repetitive pressure (leaning on elbow), occupational exposure (plumbing, gardening, carpet laying → "student's elbow")
• Fever / chills — Suggests septic bursitis / septic arthritis
• Constitutional symptoms — Weight loss, loss of appetite, night sweats (tuberculosis, malignancy)
• H/o preceding skin breach — Insect bite, abrasion, puncture wound over olecranon (entry point for septic bursitis)
• H/o joint disease elsewhere — Rheumatoid arthritis, gout (uric acid tophi at elbow), psoriatic arthritis
• H/o similar swelling in past — Recurrent bursitis

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SECTION 4: PAST HISTORY

• H/o tuberculosis / contact with TB
• H/o diabetes mellitus (immunocompromised → septic bursitis)
• H/o steroid use / fluoroquinolone use → tendinopathy
• H/o malignancy
• H/o previous surgeries around elbow

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SECTION 5: PERSONAL / SOCIAL HISTORY

• Occupation (manual laborer, plumber, gardener, student → repetitive elbow pressure)
• Smoking (associated with distal biceps tendon rupture)
• Alcohol use (gout)
• Diet (purine-rich → gout)

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SECTION 6: FAMILY HISTORY

• H/o gout, rheumatoid arthritis, psoriasis in family

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SECTION 7: DRUG HISTORY

• NSAIDs, steroids, fluoroquinolones, allopurinol, methotrexate

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PART II — CLINICAL EXAMINATION

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GENERAL EXAMINATION

• Built, nourishment, pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
• Temperature (fever → infection), pulse, BP, respiratory rate
• Skin — rheumatoid nodules, gouty tophi (ear, other joints), psoriatic plaques

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LOCAL EXAMINATION OF LEFT ELBOW

A. INSPECTION (Look)

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B. PALPATION (Feel)

⚠️ Important: Olecranon bursitis swelling is posterior and separate from the joint — elbow flexion/extension is preserved, differentiating it from a true joint effusion.

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C. RANGE OF MOVEMENT (Move)

• Flexion limited by pain in bursitis = tightening of skin over inflamed bursa
• Full painless movement = suggests isolated olecranon bursitis (not joint pathology)

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D. SPECIAL TESTS

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E. NEUROVASCULAR EXAMINATION

• Ulnar nerve — Intrinsic muscle power (1st dorsal interosseous), sensation little finger / hypothenar, Froment's sign
• Radial nerve / PIN — Wrist and finger extension
• Median nerve — "OK sign," sensation index finger pulp
• Radial pulse — Compare both sides
• Brachial artery — In supracondylar fractures (absent pulse = emergency)

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PART III — INVESTIGATIONS

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Bursal Fluid Interpretation

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PART IV — DIFFERENTIAL DIAGNOSIS

Posterior Elbow

1. Olecranon bursitis (most common) — traumatic / aseptic / septic / gouty / rheumatoid
2. Distal triceps tendon rupture — pain + swelling proximal to olecranon, diminished extension
3. Tophaceous gout — firm, irregular, uric acid crystals
4. Rheumatoid nodule — firm, subcutaneous, over pressure points
5. TB cold abscess / bursitis — painless, fluctuant, sinus formation, no heat

Joint Effusion (Lateral / Diffuse)

1. Septic arthritis — hot, red, painful, restricted all movements
2. Rheumatoid arthritis — bilateral, morning stiffness, systemic features
3. Post-traumatic hemarthrosis — following fracture/dislocation

Bony Swellings

1. Osteochondroma (sessile/pedunculated) — hard, non-tender, arising from bone
2. Malignant bone tumor (osteosarcoma, chondrosarcoma) — rare

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PART V — DIAGNOSIS

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PART VI — MANAGEMENT

Non-septic / Aseptic Bursitis

• Compression bandage, ice packs
• NSAIDs (ibuprofen / naproxen)
• Avoidance of precipitating activity (elbow padding)
• Aspiration (diagnostic + therapeutic) — relieves pressure and pain
• Intra-bursal corticosteroid injection (after ruling out infection)
• Surgery (bursectomy) — for refractory cases

Septic Bursitis

• Aspiration and drainage of bursa
• Antibiotics: cover Staphylococcus aureus (most common organism, 80–90% of cases)
  • Empirical: Co-trimoxazole DS BD or Doxycycline 100 mg BD × 10–14 days (oral)
  • If immunocompromised / severe: IV Vancomycin 15–20 mg/kg
  • MRSA coverage included empirically
• Surgical incision and drainage if refractory
• Re-check within 24–48 hours

Gouty Bursitis

• Colchicine / NSAIDs (acute attack)
• Long-term: Allopurinol (reduce uric acid), dietary modification

TB Bursitis

• Anti-tubercular therapy (ATT) × 9–12 months
• Surgical debridement / excision if refractory

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PART VII — IMPORTANT POINTS (High-Yield Exam Points)

Anatomy

1. The olecranon bursa is the only bursa of the elbow joint — located between skin and olecranon process.
2. Cubital fossa contents (lateral to medial): Really Need Beer To Be Very Nice — Radial nerve, N. (biceps tendon), Brachial artery, Bicipital aponeurosis, Vein (median cubital).
3. Hueter's triangle (equilateral at 90° flexion, straight line at full extension) — disrupted in supracondylar fracture, intact in simple elbow dislocation.

Clinical

1. Key differentiating point: In olecranon bursitis, elbow flexion and extension are preserved (bursa is extra-articular). In joint effusion/arthritis, movement is restricted.
2. "Student's elbow" / "Miner's elbow" = olecranon bursitis from repetitive pressure.
3. "Popeye joint" = bulging olecranon bursitis appearance.
4. Septic bursitis — acute onset, warm, erythematous, tender; fever in <50%; most common organism: Staphylococcus aureus.
5. Entry point for infection — skin abrasion, insect bite, or puncture over posterior elbow → bacteria spread from skin flora.
6. Cubitus valgus (>15°) — commonest cause: malunited lateral condyle fracture in children → late complication = tardy ulnar nerve palsy.
7. Cubitus varus / Gunstock deformity — commonest cause: malunited supracondylar fracture → cosmetic deformity, no neurological complication usually.

Investigations

1. Bursal fluid WBC >10,000/mm³ → septic; <1,000/mm³ → aseptic.
2. Bursal fluid: serum glucose ratio <50% in 90% of septic cases → diagnostic.
3. Gram stain positive in 70% of septic bursitis.
4. Crystals do not rule out infection (co-infection with gout + septic bursitis possible).
5. X-ray soft tissue shadow may show olecranon bursitis; bony spurs in chronic cases.

Surgical Anatomy

1. Nerve at risk in lateral epicondyle surgeries: posterior interosseous nerve (PIN) / deep branch of radial nerve.
2. Nerve at risk in medial epicondyle / cubital tunnel: ulnar nerve.
3. Anterior transposition of ulnar nerve = treatment for cubital tunnel syndrome / tardy ulnar palsy.

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PART VIII — CLINICAL IMAGE

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Quick Summary Card

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