What is a swollen elbow?

Swollen Elbow: Diagnosis and Management

A swollen elbow is a clinical presentation that can result from various pathologies including trauma, infection, arthritis, or soft tissue disorders, requiring prompt evaluation with radiography as the initial imaging modality to guide further management. 1

Causes of Swollen Elbow

• Traumatic causes:

  • Fractures and dislocations
  • Ligament injuries (ulnar collateral ligament injury)
  • Osteochondral lesions
  • Heterotopic ossification

• Infectious causes:

  • Septic arthritis
  • Soft tissue infection/cellulitis
  • Osteomyelitis
  • Tenosynovitis

• Inflammatory/Arthritic causes:

  • Rheumatoid arthritis
  • Osteoarthritis
  • Posttraumatic arthritis
  • Crystal arthropathies (gout, pseudogout)

• Other causes:

  • Bursitis (olecranon bursitis)
  • Tumor or metastatic disease 2
  • Insect sting reaction 3
  • Synovial hypertrophy

Diagnostic Approach

Initial Imaging

• Radiographs should be the first imaging study for any swollen elbow 4, 1

  • Can identify:
    • Fractures and dislocations
    • Joint effusion
    • Soft tissue swelling
    • Intra-articular bodies
    • Heterotopic ossification
    • Osteophytes and degenerative changes
    • Erosions and periosteal reaction (seen in infections)

• Comparison with the contralateral elbow is often helpful to identify asymmetry 4

Advanced Imaging (if radiographs are normal or nonspecific)

• MRI Elbow

  • Best for evaluating:
    • Soft tissue pathology
    • Ligament injuries
    • Osteochondral lesions
    • Joint effusions
    • Early osteomyelitis
    • Synovial abnormalities

• CT Elbow

  • Superior for:
    • Detailed bone anatomy
    • Loose bodies (93% sensitivity, 66% specificity) 4
    • Heterotopic ossification
    • Osteophytes

• Ultrasound

  • Useful for:
    • Joint effusions
    • Soft tissue abnormalities
    • Guiding aspiration

Diagnostic Procedures

• Image-guided aspiration is essential when infection is suspected 4
  • Allows for:
    • Identification of infectious organisms
    • Cell count and crystal analysis
    • Proper treatment planning

Management Based on Etiology

Infectious Causes

• For suspected septic arthritis or soft tissue infection:
  • Prompt aspiration and culture
  • Appropriate antibiotic therapy
  • Possible surgical debridement
  • Tuberculous arthritis should be considered in cases not responding to conventional antibiotic treatment 5

Traumatic Causes

• Treatment depends on specific injury:
  • Rest and activity modification
  • Ice application
  • NSAIDs for pain and inflammation
  • Immobilization if necessary
  • Surgical intervention for unstable injuries

Arthritic Causes

• Conservative management includes:

  • NSAIDs (oral or topical) at lowest effective dose 1
  • Activity modification
  • Physical therapy focusing on eccentric strengthening exercises
  • Corticosteroid injections (limited to 1-2 injections) 1

• Surgical options for persistent symptoms:

  • Arthroscopic debridement
  • Synovectomy
  • Total elbow arthroplasty (for end-stage arthritis in low-demand, elderly patients) 6

Clinical Pearls and Pitfalls

• Pitfall: Misdiagnosing infection as inflammatory arthritis can lead to delayed treatment and joint destruction

  • Always consider aspiration in acute, severely swollen elbow

• Pitfall: Overlooking uncommon causes like metastatic disease 2 or insect sting reactions 3

  • Consider broader differential in atypical presentations

• Pearl: The goal of treatment should be to restore functional range of elbow motion (≥30° to 130°) 1

• Pearl: Diabetic patients should be informed about the risk of transient hyperglycemia (1-3 days) following intra-articular glucocorticoid injections 1

• Pearl: Radiographs complement subsequent MRI elbow examination and should always be obtained first 4