Left Elbow Pain And Swelling In A Woodworker

HISTORY: 73yo RHD male presents with left elbow pain, swelling, erythema. 18 mo prior, he was treated for olecranon bursitis with oral antibiotics. He had persistence of pain and ultimately received a bursal injection at an outside facility, followed by resolution of symptoms. 4-6 w prior to evaluation, he had return of swelling and pain to the same elbow. Upon initial evaluation, pain was primarily over the lateral epicondyle with minimal effusion to the olecranon bursa and pain-free ROM at the elbow. Directed treatment was oral NSAIDs and occupational therapy (OT). His first OT session was 1 week later, and patient noted clinical worsening in the interim with additional swelling and redness. PHYSICAL EXAM: Left elbow with edema posterior to the olecranon with overlying erythema. Opening in skin near the olecranon with serosanguinous drainage. Full pain-free, active ROM of the elbow upon flexion/extension. 5/5 strength with resisted flexion, extension, pronation and supination. Ddx 1.Septic olecranon bursitis2.Septic elbow joint3.Crystalline arthropathy of the elbow4.Pyoderma with surrounding cellulitis TESTS AND RESULTS: XR of left elbow: no acute osseous process. ESR, CRP, CBC, uric acid were normal. POCUS: small effusion of the olecranon bursa, with soft tissue cobblestoning and proximal extension along the humerus. MRI of the left elbow with contrast: trace joint effusion with synovitis, tracking wound with extension through the olecranon bursa with no evidence of direct communication into the joint, expansion of soft tissue infection into the triceps tendon with partial tearing and retraction of the tendon, osteomyelitis of the proximal olecranon. FINAL WORKING DIAGNOSIS: Septic bursitis with osteomyelitis of the left olecranon without joint infection TREATMENT AND OUTCOMES: Patient was referred to an elbow surgeon and had a left olecranon bursectomy with debridement and partial craterization of the left olecranon. Intraoperative inspection of the triceps tendon revealed the bulk of tendon was attached and repair was not indicated. The bursa and bone fragments were sent for culture. MRSA grew from the olecranon only. He was treated with a 12-week course of Bactrim and a 6-week course of rifampin. At his most recent follow-up, he was doing well and had resumed full activity without pain or limitations.