MKSAP Quiz: swollen right elbow for two days

Stress tests overused after revascularization


A 64-year-old man with intermittent acute gout is evaluated in the office for a swollen right elbow of 2 days' duration. He recalls no inciting trauma. His last attack of gout occurred 4 months ago and involved his right knee. He takes no medications.

On physical examination, temperature is 38.1 °C (100.5 °F). The right elbow is warm with minimal erythema. Musculoskeletal examination reveals slight fullness and tenderness over the right olecranon process. Passive and active extension of the right elbow is painless, but passive flexion greater than 90 degrees elicits pain. Rotation of the forearm is painless. He is able to extend the arm fully without discomfort.

Which of the following is the most appropriate next step in this patient's management?

A. Empiric trial of colchicine
B. Measurement of erythrocyte sedimentation rate
C. Radiograph of the right elbow and forearm
D. Right elbow joint aspiration
E. Right olecranon bursa aspiration

Reveal the Answer

MKSAP Answer and Critique

The correct answer is E) Right olecranon bursa aspiration. This item is available to MKSAP 15 subscribers as item 25 in the General Internal Medicine module.

Immediate aspiration of the right olecranon bursa is indicated for this patient. There is a strong clinical suspicion for olecranon bursitis, which may be infectious, crystalline, or traumatic. Synovial fluid analysis will help guide therapy in this setting. Acute crystalline or infectious synovitis usually is associated with extreme pain on passive joint motion. This patient has pain only on full flexion of the joint, most likely because this movement causes tautness of the bursa and surrounding soft tissue.

If gout were evident on the synovial fluid analysis, a trial of colchicine would be reasonable.

Measurement of the erythrocyte sedimentation rate will not help to distinguish between crystal-induced arthritis and infection.

Radiography is useful in evaluating traumatic causes of acute pain near a joint but would not help to differentiate between crystalline and infectious arthritis or to diagnose bursitis. Nuclear scanning and MRI are similarly not particularly useful in establishing a diagnosis among these conditions.

Joint aspiration is not indicated in the absence of convincing evidence that the joint itself is the source of the problem, such as painful elbow joint rotation or extension.

Key Point

  • Olecranon bursitis is typically associated with painful full elbow flexion; acute crystalline or infectious synovitis is usually associated with pain on any passive joint motion.