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What's causing the swelling on this man's elbow?

Dr Mike Wyndham describes how he got to the root cause of the swelling on this labourer’s arm

 

The patient

This 27-year-old man – who works as a labourer on a local building site – came in with a painful elbow, which had developed over the previous 48 hours. It had become a problem as it was affecting his ability to lift and he was concerned about losing money if he had to go off sick. His health has always been good, apart from a fractured tibia playing football five years ago.

First instinct

There was a definite swelling over the olecranon, which fitted with an olecranon bursitis. The swelling was smooth and there were no lumps palpable in it. His job would put him at risk of trauma so this might be a strong possibility, but why the redness? His temperature was 37.5°C.

Differential diagnosis

• Rheumatoid arthritis

• Pseudogout/gout

• Trauma

• Infection, for example local or from haematogenous spread

Rheumatoid arthritis is much more common in women than men. There were certainly no nodules in the bursa or along the forearm. The rest of his joints, despite being a labourer for a few years, were in good condition with nothing to suggest a synovitis. An inflammatory arthritis seemed unlikely.

Gout is certainly more common in men than women and the majority of cases occur between the ages of 30 and 60. So right sex, wrong age. Pseudogout is most likely to affect shoulder, wrist and knee and have slow onset lasting a few days. The speed of onset was perhaps a bit too quick. Gout will commonly attack the foot but it is often acute and the sudden development might fit.

Repeated rubbing of the elbow may cause the bursa to swell but the patient had no history of this. The surface of the skin over the bursa was intact with no sign of infection.

Getting on the right track

Trauma, rheumatoid arthritis and gout seemed to be ruled out here, so infection seemed likely. The question was where had the infection arisen from. I explained this to him as I was rather puzzled. He then volunteered some vital information. He had been rather bothered by a boil on his hand that had turned crusty. It had been throbbing a couple of days earlier, so he decided to ‘sterilise' a needle and see if he could puncture the boil. Despite three attempts he had been unsuccessful.

It seemed a strong possibility that infection may have been spread during the home treatment of the boil. The bursa was drained revealing some pus. He was started on flucloxacillin with a successful outcome.

Dr Mike Wyndham is a GP in Edgware, north London

What's causing the swelling on this man's elbow? What's causing the swelling on this man's elbow?

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