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A Trivial Hit to the Elbow that Wasn’t Trivial


Authors:  Shiny M Varghese M.D., Vidya S. Kollu M.D., and Susan J. Smith M.D

    A 47 year old Caucasian female with a history of operative repair of an olecranon fracture, with retained hardware, came to the emergency room with severe right elbow pain, redness and swelling. The symptoms began after hitting her elbow against a table four days prior to presentation. There was no history of diabetes, intravenous drug use or immunosuppression.         

   On presentation, her heart rate was 103/min and blood pressure was 89/57 mm Hg. She was afebrile. The right elbow exam was significant for tenderness, erythema, warmth and swelling of a 10 x 8 cm area, with overlying necrotic skin changes. Laboratory studies were significant for a white blood cell count of 16,200 cells/µL with 89% neutrophils. C-reactive protein and erythrocyte sedimentation rate were markedly elevated. X-rays showed subcutaneous air as shown in Images 1 and 2 below. The patient was treated with broad spectrum intravenous antibiotics including clindamycin, ampicillin-sulbactum and ciprofloxacin. At surgical debridement, purulent subcutaneous tissue and necrotic muscle were excised. Cultures grew methicillin-sensitive Staphylococcus aureus and Peptostreptococcus anaerobius and antibiotics were targeted per sensitivities, as clindamycin and ciprofloxacin were discontinued.

 MCQ 1: Which of the following is the definitive way to diagnose this condition?

 A. MRI of right elbow
 B. CT of right elbow
 C. Surgical exploration
 D. Clinical findings

MCQ 2: Which of the following is the most common organism isolated in this condition?

  1. Pseudomonas aeruginosa
  2. Streptococcus pyogenes
  3. Staphylococcus aureus
  4. Clostridium perfringens

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Author Information

Shiny M Varghese M.D is currently a third year resident in Internal Medicine at McLaren Regional Medical Center in Flint, Michigan. She anticipates practicing outpatient medicine near Los Angeles after finishing her residency.

Vidya S. Kollu, MD, is a Clinical Assistant Professor at McLaren Regional Medical Center in Flint, Michigan. He is a practicing general internist. He attends patients in the inpatient and outpatient settings.

Susan J. Smith, MD, is the Program Director at McLaren Regional Medical Center in Flint, Michigan. She is a practicing general internist, geriatrician and palliative medicine physician. She attends patients in the outpatient setting and in skilled nursing facilities