What is the appropriate management for a patient with a swollen, warm, and painful elbow, considering potential infectious or inflammatory processes and possible past medical history of injuries, conditions, or surgeries?

Management of Swollen, Warm, and Painful Elbow

A swollen, warm, and painful elbow requires immediate arthrocentesis with synovial fluid analysis to exclude septic arthritis if infection cannot be clinically ruled out, followed by plain radiographs as the initial imaging study to identify osseous pathology, calcifications, or fractures. 1, 2

Immediate Clinical Priorities

Rule out septic arthritis first when the elbow is warm to touch with acute swelling, as this represents a surgical emergency requiring urgent intervention. 2 The presence of warmth, acute onset, and systemic signs (fever, elevated inflammatory markers) mandate image-guided arthrocentesis with synovial fluid culture and empiric IV antibiotics pending culture results. 2 Ceftriaxone provides broad-spectrum coverage for common pathogens including Staphylococcus aureus, which is the most common cause of septic arthritis. 3

Initial Diagnostic Workup

• Obtain plain radiographs (AP and lateral views) immediately as the first-line imaging study to identify intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcifications, occult fractures, or osteoarthritis. 4, 1, 2
• Compare with the contralateral asymptomatic elbow when findings are subtle or equivocal. 4, 1, 2
• Perform arthrocentesis with synovial fluid analysis when infection cannot be excluded based on clinical presentation (warmth, acute swelling, systemic signs). 2

Red Flag Assessment

Specific clinical features guide the differential diagnosis and subsequent management:

• Night pain or pain at rest suggests inflammatory or neoplastic processes requiring urgent investigation. 1
• Mechanical symptoms (locking, clicking, catching) indicate intra-articular pathology such as osteochondral lesions or loose bodies. 1, 2
• Diffuse unilateral swelling may indicate upper extremity DVT, particularly with risk factors for thrombosis. 1

Location-Specific Examination

For lateral elbow pain with swelling:

• Test for pain with resisted wrist extension (lateral epicondylitis). 1
• Assess for mechanical symptoms suggesting osteochondral lesions of the capitellum or radial head. 1

For medial elbow pain with swelling:

• Perform valgus stress testing for UCL injury. 1
• Assess for medial joint line tenderness (distinct from the epicondyle). 1
• Check for ulnar nerve subluxation with elbow flexion/extension. 1

Advanced Imaging Based on Initial Findings

If radiographs are normal or nonspecific:

• MRI elbow without contrast is indicated for suspected tendon tear, nerve entrapment, or soft tissue pathology. 1
• MR arthrography (3T) offers 100% sensitivity for detecting intra-articular bodies and evaluating osteochondral lesion stability, with 81% sensitivity and 91% specificity for UCL injury in throwing athletes. 1
• CT arthrography provides 93% sensitivity for loose bodies and excellent assessment of heterotopic ossification. 1
• Ultrasound has 94% sensitivity and 98% specificity for common extensor tendon tears when advanced techniques are used. 1

Treatment Algorithm

For inflammatory conditions (lateral epicondylitis, tendinitis):

• Begin with relative rest, activity modification, and eccentric strengthening exercises (80% recover within 3-6 months). 1
• Apply cryotherapy for 10-minute periods for acute pain relief. 1
• Use counterforce bracing to improve function during daily activities. 1
• NSAIDs such as ibuprofen provide symptomatic relief for pain and inflammation. 5
• Corticosteroid injections are more effective than NSAIDs acutely but do not change long-term outcomes. 1

For heterotopic ossification:

• Obtain CT elbow to define extent and maturity of ossification. 2
• Manage conservatively with NSAIDs and gentle range-of-motion exercises. 2

For septic arthritis:

• Immediate arthrocentesis with culture and empiric IV antibiotics (ceftriaxone) pending culture results. 2, 3

Critical Pitfalls to Avoid

• Never skip initial radiographs before assuming soft tissue injury, as osseous pathology must be excluded first. 1, 2
• Do not order MRI before plain radiographs, as MRI is less sensitive for calcifications and osseous abnormalities. 2
• Avoid over-reliance on corticosteroid injections, which may lead to tendon rupture with repeated use. 2
• Do not miss septic arthritis when swelling is acute with warmth and systemic signs—this requires urgent arthrocentesis. 2
• Avoid complete immobilization, which leads to muscle atrophy and joint stiffness; gentle range-of-motion exercises are preferred. 2
• Consider referred pain from cervical spine pathology or radial tunnel syndrome when initial imaging is negative. 1