What is the appropriate workup and management for a 19‑year‑old female presenting with an acutely swollen, red, tender right elbow?

Acute Swollen, Red, Tender Elbow in a 19-Year-Old Female

This presentation requires immediate evaluation for septic arthritis or septic bursitis, which are orthopedic emergencies that can lead to permanent joint damage if not treated within 24-48 hours.

Immediate Diagnostic Workup

Clinical Assessment

• Obtain plain radiographs of the elbow immediately (AP, lateral, and oblique views) as the mandatory first imaging study to identify fractures, joint effusions, and exclude bony pathology 1.
• Look specifically for fever, spreading erythema, or systemic symptoms that indicate osteomyelitis or septic arthritis requiring urgent intervention 2.
• Assess for rapid progression with warmth and redness, which strongly suggests an infectious process 2.

Laboratory Evaluation

• Draw serum C-reactive protein (CRP) urgently—a level >10.5 mg/dL is highly predictive of septic arthritis and warrants immediate surgical consultation 3.
• Obtain complete blood count, erythrocyte sedimentation rate, and blood cultures if infection is suspected 4.

Joint Aspiration

• Perform arthrocentesis immediately if septic arthritis is suspected to obtain synovial fluid for cell count, Gram stain, and culture 5, 3.
• Do not delay treatment waiting for culture results if clinical suspicion is high—Gram stain may be negative even in culture-positive septic arthritis 3.

Management Algorithm

If Septic Arthritis is Suspected (Based on Clinical Presentation + CRP >10.5 mg/dL)

• Proceed directly to arthroscopic irrigation and debridement within 24-48 hours of symptom onset 5.
• Treatment within 2 days of symptom onset results in 100% scores for pain relief, function, and range of motion, compared to significantly worse outcomes with delayed treatment 5.
• Start empiric IV antibiotics immediately after obtaining cultures, targeting Staphylococcus aureus (the most common pathogen) 4.
• Continue antibiotics for at least 5 days after documented culture sterility on serial aspirations 6.

If Septic Bursitis is Suspected (Olecranon Bursa)

• Perform immediate aspiration for decompression and culture 7.
• Start oral or IV antibiotics promptly to prevent septicemia 7.
• Perform frequent needle drainage (serial aspirations every 2-3 days) until cultures are sterile 6.
• Treatment delay beyond 2 weeks significantly prolongs culture-positivity despite adequate antibiotics (average 4 days to sterility when treated early vs. much longer with delay) 6.

If Radiographs Show Fracture or Trauma

• Follow standard trauma protocols with CT without contrast if fracture is suspected but radiographs are indeterminate 8, 1.
• MRI without contrast is appropriate if soft tissue injury is suspected with normal radiographs 8, 1.

Critical Pitfalls to Avoid

• Never delay treatment waiting for culture results—the duration of symptoms before treatment directly correlates with delayed response to antibiotics (r = 0.68, P <0.001) 6.
• Do not dismiss the diagnosis based on negative Gram stain alone—many culture-positive cases have negative initial Gram stains 3.
• Do not treat conservatively with NSAIDs and rest if infection is suspected—this approach is only appropriate for confirmed non-infectious soft tissue injuries 1.
• The elbow is a rare location for septic arthritis, which often leads to diagnostic errors and delays—maintain high clinical suspicion in any elbow with persistent pain and functional limitation lasting 24-48 hours 4.

Prognosis

• Septic elbow arthritis carries high morbidity and mortality, particularly in immunocompromised patients 5.
• Early arthroscopic treatment (within 2 days) achieves excellent functional outcomes with Mayo Elbow Performance Scores of 100% 5.
• Delayed treatment or reoperation is associated with poor outcomes (62.5% pain relief, 85.4% function) 5.