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Non-traumatic Unilateral Elbow Effusion In A Seventeen Year-old Cheerleader: 144 May 28 1110 AM - 1130 AM

Requa, Eric D.O.

Medicine & Science in Sports & Exercise: May 2014 - Volume 46 - Issue 5S - p 21–22
doi: 10.1249/01.mss.0000493229.10799.75
A-32 Clinical Case Slide - Elbow Issues May 28, 2014, 9:30 AM - 11:30 AM Room: 306
Free

York Hospital, York, PA. (Sponsor: Mark Lavallee, M.D., C.S.C.S., FACSM)

(No relationships reported)

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.

PHYSICAL EXAM:

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)

DIFFERENTIAL DIAGNOSIS:

1. Medial & Lateral Epicondylitis

2. Olecranon bursitis

3. Septic arthritis

4. Gout/Pseudogout

5. SLE

6. Ehlers-Danlos Syndrome

7. Fracture

8. Malignancy

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

FINAL/WORKING DIAGNOSIS:

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.

© 2014 American College of Sports Medicine