How to manage severe left elbow pain and limited ROM in a patient with a history of CPR, hyponatremia, and multiple chronic conditions?

From the Guidelines

The patient's severe left elbow pain and limited range of motion should be managed with a comprehensive approach, starting with radiography of the elbow as the initial imaging, followed by conservative treatment including physical therapy and NSAIDs, while closely monitoring sodium levels and avoiding opioids if possible, as recommended by the American College of Radiology in 2022 1.

Initial Assessment and Imaging

The patient's history of CPR and current complaints of severe left elbow pain and limited range of motion necessitate a thorough assessment. Initially, an X-ray of the left elbow should be obtained to assess for fractures, dislocations, or soft tissue injuries potentially related to CPR chest compressions, as radiography is usually appropriate for the initial imaging of chronic elbow pain 1.

Conservative Management

Conservative treatment should include physical therapy, focusing on gentle range of motion exercises and gradually progressing to strengthening. NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) can be used for pain and inflammation, being cautious with dosing given the patient's medical complexity. Consider a short course of oral prednisone (20mg daily for 5-7 days) if inflammation is significant. For breakthrough pain, acetaminophen (up to 3000mg daily in divided doses) can be added, avoiding opioids if possible due to the risk of respiratory depression in a vulnerable patient.

Monitoring and Follow-Up

Monitor sodium levels closely, as hyponatremia can worsen with certain medications and impact recovery. If pain persists after 2-3 weeks of conservative management, consider corticosteroid injection into the elbow joint. Surgical consultation may be necessary if symptoms persist beyond 6-8 weeks or if imaging reveals structural damage requiring repair. Throughout treatment, maintain close coordination with the patient's primary care physician to monitor chronic conditions and medication interactions.

Key Considerations

• Avoid opioids if possible due to the risk of respiratory depression in a vulnerable patient.
• Monitor sodium levels closely to prevent worsening of hyponatremia.
• Coordinate care with the patient's primary care physician to manage chronic conditions and medication interactions effectively.
• Consider advanced imaging such as MRI or CT if initial radiographs are normal or nonspecific and symptoms persist, as recommended for suspected intra-articular pathology or occult stress fracture 1.

From the Research

Patient Assessment and Diagnosis

• The patient presents with severe left elbow pain and limited range of motion (ROM) following a CPR incident last April, with a history of hyponatremia and multiple chronic conditions.
• The patient's symptoms and medical history suggest the need for a comprehensive evaluation to determine the underlying cause of the elbow pain and limited ROM.

Management of Elbow Pain and Limited ROM

• According to 2, the evaluation of elbow pain in adults should include a thorough history and physical examination to localize the injury to one of the four anatomic regions: anterior, medial, lateral, or posterior.
• The patient's limited ROM and severe pain suggest the possibility of soft tissue contractures or osseous deformities, which may require conservative treatment with physiotherapy (PT) and splinting, or early surgical intervention 3.
• The use of plain radiography as the initial choice for evaluating acute injuries, and magnetic resonance imaging for chronic elbow pain, may be necessary to determine the underlying cause of the patient's symptoms 2.
• The patient's history of CPR and trauma suggests the possibility of traumatic elbow injuries, which may require advanced imaging techniques and early intervention to prevent instability or poor functional outcomes 4.

Treatment Options

• Conservative treatment with PT and splinting may be effective in managing soft tissue contractures and improving ROM 3.
• The use of neural mobilization techniques, ultrasound, strengthening exercises, and stretching may be beneficial in managing lateral elbow pain with signs of nerve entrapment 5.
• In cases where osseous deformities limit ROM, early surgical intervention may be necessary, with options including open and arthroscopic arthrolysis 3.
• The patient's young age and active status may make interposition arthroplasty a viable option for managing an unstable, arthritic elbow joint 6.

Medication Management

• The patient's current medication regimen, including Ure-Na Pow (Urea), Boost (Advera) Liq, Divalproex Sodium Dr Tab (Depakote), and Escitalopram Tab (Lexapro), should be reviewed and adjusted as necessary to manage the patient's chronic conditions and prevent potential interactions with new medications.
• The patient's history of hyponatremia and multiple chronic conditions requires careful consideration when prescribing new medications, such as tramadol, to manage the patient's elbow pain.