A-32 Clinical Case Slide - Elbow Issues May 28, 2014, 9:30 AM - 11:30 AM Room: 306
HISTORY: A 17 year-old female cheerleader presents for evaluation of right elbow pain. She reports right elbow pain and swelling for several days, after simply lifting a heavy book bag and hearing a “pop.” The pain has not improved with 2% diclofenac cream. She reports limited extension of the right elbow. She denies recent trauma, illness and fevers. She denies previous surgery to the elbow. Initial visit to an orthopedist ruled out fracture with radiographs, noted joint laxity and made referral. PMH: non-traumatic right shoulder dislocation, right spontaneous pneumothorax.
Right elbow: Mild swelling, limited extension, limited pronation, supination normal. Positive tenderness to palpation of lateral epicondyle, extensor mass, and medial epicondyle. Valgus and varus stress tests were negative. Strength is 4/5 with elbow flexion/extension. Sensory and vascular intact
Left elbow: 30 degrees of recurvatum, otherwise normal exam
Hands: Finger dexterity >90 degrees of hyperextension at MCPs
Ankle: B/L sub-talar laxity
Skin: Pinchable in palm of hand. No signs of cutis laxa or “cigarette paper” scarring
Neuro: Motor and sensory otherwise grossly intact
Beighton scale 8/9 (-1 for R elbow flexion/contraction d/t effusion)
1. Medial & Lateral Epicondylitis
2. Olecranon bursitis
3. Septic arthritis
6. Ehlers-Danlos Syndrome
TEST AND RESULTS:
MRI of right elbow - No fracture. Trace fluid in elbow joint.
MRI of cervical spine - Chiari 1 malformation with CSF flow obstruction suspected at the foramen magnum.
COL3A1 gene testing- vascular EDS - negative
Unilateral right elbow effusion secondary to cartilage injury in a patient with Ehlers-Danlos syndrome and Chiari Malformation
TREATMENT AND OUTCOME:
Ketoprofen 20%/Ketamine 5%/Nortriptyline 5%/Lidocaine 5% topical cream TID x 4 weeks. Physical Therapy with focus on ROM and pain reduction using stim, phonophoresis, acupuncture and desensitization. Follow-up in 6 weeks showed significant improvement.