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Elbow Case Study 1

Elbow Case Study 1

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Published by superhoofy7186

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Published by: superhoofy7186 on Jan 30, 2009
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Elbow Case Study 1: Olecranon BursitisAnatomy & Pathology
A Bursa is a small sac that contains fluid – fluid is similar to fluid in the oint – synovial fluid. There are several Bursae in the body – one just over the olecranon –  bursa help make movements smooth between bones which stick out and the nearbyoverlying skin.The bursa is located quite superficially on the extensor side of the olecranonon – it iseasily irritated and inflamed. Bursitis may arise from trauma – from falls or direct blows. It ay also arise from prolonged irritation – and it may be assosciated wthsystemic inflammatory conditions such as Rhematoid Arthritis and gout. Furthermoreinfection ay develop in the bursa – this is known as septic bursitis. In bursitis – the bursa becomes inflamed – it swells and extra fluid is made.The location of the ulnar nerve is significant. It can become entrapped by spreadinginflammation around the olecranon.
Subjective Examination
: pain at olecranon and down posterior arm
: 6 weeks ago
: ask – has trauma been involved ?
0-10 rating
: intermittent and increasing – nb most bursitis evidences no pain !
24 hour cycle
: n/a
Better for
: rest
Worse for
: contact – ask what is it like putting on a shirt – this will give you an ideaof the severity of the patients symptoms
Type of pain
: diffuse pain
Past Medical History/ General History
: none – but ask do they suffered from goutOr rheumatoid arthritis
Red Flags and general concerns
: the pain the patient experiences is unusual – hasthere been trauma is the wound going septic – is there nerve entrapment. Ask the
 patient if they are experiencing fevers chills or sweats – these would be an indicationof infection
: still caring for young daughter 
: non – ask about DMARDS and colchicine – (an anti-gout drug)
Patients main outcome
: this could be something like returning to work 
Objective Examination
Working Hypothesis
:We can approach the patient expecting to confirm Bursitis – the bigger questions arehas there been any trauma , has the bursitis become septic and is there any nerveentrapment.
Advice & Consent
: Explain the examination – counsel about short termside effects – and obtain consent.
General Observations
: Watch the way the patient carrys their elbow – watch the way they take off any clothes.
Acute Observations
:Skin colour – lacerations and bruising may be a sign of trauma – while redness andheat may be a sign of infection.Swelling – up to 6cm in diameter Posture – depends on how they are carrying their affected elbow – are they protectingit.Muscle Bulk – may be some decrease in bulk of elbow flexors – reduced elbowflexion can be anticipated
Active Tests
: Position the patient sitting up in supine – or sitting across thecorner of the bed.
Flexion - can be painful – streches bursa at end – is diffuse pain assosciated withulnar nerve ?ExtensionPronationSupination
Passive Tests
: Check joint integrity – if there has been trauma the end feelmight be different – residue of a fracture ?Flexion – can painful – streches bursaExtensionPronationSupination
Resisted Tests
: Any weakness may be due to inactivityFlexion – painful ? – as aboveExtensionPronationSupination
Special Tests
:Varus and Valgus – test integrity of joint ( trauma )Tinels sign – tap groove for ulnar nerve – tingling => neuropathyReverse Phalens test – hold hands in prayer position for 1 minute – tingling =>neuropathy
Functional Tests
:Ask patient to put jumper on and off – watch to see how they might avoid and react to thesensation of the bursa being touched by clothing.
:Expect equisite tenderness if infected – less painful if simply chronic swellingPercuss surrounding bones where appropriate seeking a fracture – displace bones if  painful reaction to percussion. This is a further fracture test.
:Measure the size of the bursa. Compare this with other side. Measure pain at flexion.

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