Diagnostic Assessment — Left Elbow - Olecranon Bursitis
Example 1 of 1 · fictitious patient (Veteran EF)
Diagnostic Assessment
Left Elbow - Olecranon Bursitis
BOP Code: 64 of 2018 (Olecranon Bursitis)
RH Code: 63 of 2018 (Olecranon Bursitis)
ADF History
Veteran EF, date of birth 25 November 1980, Australian Army, Armoured Corps Crewman (Cavalry, later Crew Commander), enlisted 08 January 2000, medically discharged 26 July 2019. Operational service: Iraq, 15 April 2005 to 30 October 2005 (warlike); Afghanistan, 01 February 2012 to 15 September 2012 (warlike).
Occupational History
As an armoured crewman and crew commander the veteran spent long hours standing in the turret hatch of a light armoured vehicle, braced on his elbows against the steel hatch rim, and repeatedly knocked his elbows on hatches, weapon mounts and fittings while the vehicle moved over rough ground. Vehicle maintenance involved kneeling and leaning on elbows on steel decks and track guards.
Armoured crewmen commonly develop elbow and knee bursitis from repeated pressure and knocks, and sustain cuts and abrasions in confined steel compartments. On deployment, skin wounds were exposed to dust, sweat and heat with limited hygiene, increasing the risk of infection.
History
Veteran EF, an armoured crewman in the Australian Army, developed septic olecranon bursitis of the left elbow on warlike service in Afghanistan on 18 June 2012, 16 days after a laceration over the elbow was surgically closed, after months of bracing his elbows on the turret hatch rim, and while he had psoriasis of the elbows, gout, type 2 diabetes and chronic myeloid leukaemia treated with imatinib. The bursitis worsened with a recurrent abscess and cellulitis on 20 August 2012, after incision and drainage on deployment, and became chronic.
Timeline
- 14 Mar 2008 — A dermatologist confirmed chronic plaque psoriasis, with thick plaques on the extensor surfaces of both elbows and the knees, and commenced topical treatment. The veteran reported the plaques cracked and bled with pressure on the elbows in the vehicle turret. His elbows were otherwise normal. "psoriasis, extensor elbow plaques"
- 22 Sep 2010 — He had a second attack of acute gout in the right first metatarsophalangeal joint, with a serum urate of 0.61 mmol/L, and allopurinol was commenced. Type 2 diabetes mellitus was diagnosed with an HbA1c of 7.2 per cent and metformin commenced. BMI 31. "gout, type 2 diabetes"
- 07 Apr 2011 — Investigation of a raised white cell count of 48 x 10^9/L found the Philadelphia chromosome and BCR-ABL1 transcript, and a haematologist diagnosed chronic myeloid leukaemia in chronic phase. Imatinib, a tyrosine kinase inhibitor, 400 mg daily was commenced. By January 2012 he had a major molecular response and was cleared for deployment with a supply of imatinib. "CML, imatinib 400 mg daily"
- 02 Jun 2012 — During warlike service in Afghanistan he cut the back of his left elbow on the sharp edge of the turret hatch when the vehicle lurched, a 3 cm laceration over the olecranon through a psoriatic plaque. The wound was debrided and sutured at the role 2 facility the same day. He returned to crew commander duties, standing in the hatch with his elbows braced on the rim for six to eight hours a day. "left elbow laceration sutured"
- 19 Jun 2012 — He presented with a day of painful swelling over the back of the left elbow, warmth, redness and fever of 38.2 degrees, beginning on 18 June 2012. Examination showed a fluctuant olecranon bursa 5 cm across with surrounding cellulitis and a healing laceration with an active psoriatic plaque. Aspiration yielded purulent fluid that grew Staphylococcus aureus, with no crystals. Oral flucloxacillin was commenced and imatinib continued. "septic olecranon bursitis, S. aureus"
- 30 Jul 2012 — The bursa had reaccumulated despite antibiotics and repeated needle aspiration on 05 and 19 July 2012, and the surgeon at the role 2 facility performed incision and drainage of the left olecranon bursa under local anaesthetic. He was returned to duties after five days, again bracing his elbows in the turret hatch. "incision and drainage, left bursa"
- 20 Aug 2012 — He re-presented with a recurrent abscess of the left olecranon bursa, spreading cellulitis to the mid-forearm, a discharging sinus and fever of 39 degrees. Culture grew methicillin-resistant Staphylococcus aureus, and aspirated fluid also contained monosodium urate crystals. He was aeromedically evacuated to the role 3 hospital for intravenous vancomycin. "recurrent abscess, MRSA, urate crystals"
- 14 Nov 2012 — After his return to Australia an orthopaedic surgeon performed open excision of the chronically thickened left olecranon bursa, with a gouty tophus and a bony spur on the olecranon. Histology showed chronic inflammation with urate deposits. He was left with a tender scar and recurrent swelling with pressure. "bursectomy, chronic bursitis, tophus"
Symptoms
At onset the veteran had painful swelling over the back of the left elbow, redness, warmth and fever, with pain on leaning on the elbow and on full bending. After onset the swelling recurred despite aspiration and drainage, and in August 2012 he developed an abscess with spreading redness of the forearm, a discharging sinus and high fever.
He now reports recurrent swelling and tenderness over the back of the left elbow after leaning on it, a tender bursectomy scar, and pain with pressure, so that he cannot rest his elbow on a desk, armrest or car door.
Imaging
- 19 Jun 2012 — Ultrasound left elbow: "Distended olecranon bursa measuring 48 x 22 mm with thickened hyperaemic walls and echogenic debris, and surrounding subcutaneous oedema."
- 20 Aug 2012 — Ultrasound left elbow: "Recurrent complex collection in the olecranon bursa measuring 55 x 30 mm with a sinus tract to the skin and extensive surrounding cellulitis. Echogenic aggregates consistent with tophaceous material."
- 28 Sep 2012 — X-ray left elbow: "Olecranon enthesophyte (spur) and a soft tissue density over the olecranon with faint calcification. No erosion or osteomyelitis."
Onset Date
The most likely date of onset of this condition is 18 Jun 2012.
At that date the veteran was on warlike service in Afghanistan as a crew commander of a light armoured vehicle, standing in the turret hatch with his elbows braced on the rim for six to eight hours a day, 16 days after a laceration over the left olecranon had been surgically closed. On 18 June 2012 painful swelling and redness developed over the back of the left elbow.
This date is appropriate because the wound review of 09 June 2012 recorded a clean healing laceration with no bursal swelling, and he presented with septic bursitis on 19 June 2012, the day after symptoms began. It falls within warlike service.
For the trauma and surgery factors, the 30 days before onset run from 19 May 2012 to 18 Jun 2012, and the laceration and its surgical debridement and closure occurred on 02 Jun 2012, with repeated rubbing and knocking of the elbow on the hatch rim on almost every day of that period. For the tyrosine kinase inhibitor factor, he took imatinib 400 mg daily throughout the same 30 days. Bacterial infection of the bursa, chronic myeloid leukaemia, imatinib treatment, type 2 diabetes, gout and psoriasis of the extensor left elbow were each present on 18 Jun 2012.
For the worsening factors, the period after onset runs from 18 Jun 2012 to the documented worsening on 20 Aug 2012. The 30 days before the worsening run from 21 Jul 2012 to 20 Aug 2012, during which he underwent incision and drainage of the bursa on 30 Jul 2012, continued to brace his elbows in the turret hatch, and took imatinib daily. The infection, the leukaemia and its treatment, diabetes, gout and psoriasis were present on 20 Aug 2012.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Elbow - Olecranon Bursitis (ICD-10 M70.2), septic at onset, with gouty involvement, later chronic, under the Statements of Principles concerning olecranon bursitis, Balance of Probabilities No. 64 of 2018 and Reasonable Hypothesis No. 63 of 2018.
The olecranon bursa is a thin fluid-filled sac lying between the skin and the bony point of the elbow. Bursitis is inflammation of the bursa, which fills with fluid and becomes swollen and tender. It is caused by repeated pressure, rubbing and knocks to the elbow, by direct injury, by infection entering through a cut or abrasion, and by gout and other crystal deposits. Septic bursitis is more common and more severe in people with diabetes, inflammatory skin disease over the elbow and lowered immunity from cancer or its treatment. Recurrent or chronic bursitis may need surgical excision.
The condition began on warlike service in Afghanistan on 18 June 2012, 16 days after a surgically closed laceration over the elbow, and worsened with a recurrent abscess and cellulitis on 20 August 2012.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 June 2012.
When did the veteran first present to a health / medical provider for this condition?
19 June 2012.
When was the condition confirmed / formally diagnosed?
19 June 2012.
When did the veteran first present to you (or your practice) for this condition?
29 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on 19 June 2012 by a fluctuant, tender, warm swelling of the left olecranon bursa with surrounding cellulitis, ultrasound showing a distended thick-walled bursa containing debris, and aspiration of purulent fluid that grew Staphylococcus aureus. This meets the Statement of Principles definition of olecranon bursitis, in its septic form.
The worsening was confirmed on 20 August 2012 by a recurrent abscess with a sinus and spreading cellulitis, ultrasound and culture of methicillin-resistant Staphylococcus aureus, with monosodium urate crystals in the aspirate. Chronic bursitis with urate deposits was confirmed histologically after bursectomy on 14 November 2012.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 18 June 2012, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2012, where the condition began and worsened. The Balance of Probabilities instrument applies to peacetime service, during which his psoriasis, gout, type 2 diabetes and chronic myeloid leukaemia were diagnosed and treated, and during which his duties in the turret hatch began.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Olecranon Bursitis, No. 64 of 2018
Causative factors
Factor 8(1): having a bacterial, fungal or algal infection involving the affected bursa at the time of the clinical onset of olecranon bursitis; — MET
- Aspiration of the left olecranon bursa on 19 June 2012 yielded purulent fluid that grew Staphylococcus aureus, a bacterial infection of the affected bursa present at onset on 18 June 2012. The organism entered through the laceration sustained on duty on 02 June 2012.
Factor 8(2): having trauma to the external elbow of the affected side in the 30 days before the clinical onset of olecranon bursitis; — MET
- On 02 June 2012, 16 days before onset, the veteran lacerated the back of his left elbow on the edge of the turret hatch, and throughout the 30 days before onset, from 19 May to 18 June 2012, he braced and rubbed his elbows on the steel hatch rim for six to eight hours a day and repeatedly knocked them on fittings. Both are trauma to the external left elbow sustained in the course of his duties as a crew commander.
Factor 8(3): having surgery to the external elbow of the affected side in the 30 days before the clinical onset of olecranon bursitis; — MET
- The laceration over the left olecranon was surgically debrided and sutured at the role 2 facility on 02 June 2012, 16 days before onset, as recorded in the wound management record.
Factor 8(4): for septic olecranon bursitis only, being in an immunocompromised state as specified at the time of the clinical onset of olecranon bursitis; — MET
- The bursitis was septic. At onset the veteran had chronic myeloid leukaemia, a haematological malignancy diagnosed on 07 April 2011, and was taking imatinib 400 mg daily, a chemotherapeutic agent for cancer, so he was in an immunocompromised state as specified on 18 June 2012.
Factor 8(5): having a disorder from the specified list of disorders at the time of the clinical onset of olecranon bursitis; — MET
- Type 2 diabetes mellitus, diagnosed on 22 September 2010 with an HbA1c of 7.2 per cent, and gout, confirmed in 2010 with a serum urate of 0.61 mmol/L, were both present at onset on 18 June 2012. Both are on the specified list of disorders, and urate crystals were later found in the bursal fluid.
Factor 8(6): having psoriasis, localised sclerosis, atopic dermatitis or another inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected elbow, at the time of the clinical onset of olecranon bursitis; — MET
- Chronic plaque psoriasis involving the extensor surfaces of both elbows was confirmed by a dermatologist on 14 March 2008, and an active plaque over the left olecranon, through which the laceration ran, was recorded at onset on 19 June 2012.
Factor 8(7): being treated with a tyrosine kinase inhibitor within the 30 days before the clinical onset of olecranon bursitis; — MET
- The veteran took imatinib 400 mg daily, a tyrosine kinase inhibitor prescribed by a haematologist for chronic myeloid leukaemia, continuously from 07 April 2011, including every day of the 30 days before onset, from 19 May to 18 June 2012.
Worsening factors
Factor 8(8): having a bacterial, fungal or algal infection involving the affected bursa at the time of the clinical worsening of olecranon bursitis; — MET
- Culture on 20 August 2012 grew methicillin-resistant Staphylococcus aureus from the recurrent abscess of the left olecranon bursa. The worsening was documented that day, with a discharging sinus, cellulitis spreading to the mid-forearm and fever of 39 degrees, requiring evacuation for intravenous vancomycin.
Factor 8(9): having trauma to the external elbow of the affected side in the 30 days before the clinical worsening of olecranon bursitis; — MET
- In the 30 days before the worsening, from 21 July to 20 August 2012, the bursa was incised on 30 July 2012, and the veteran returned to duties on 04 August 2012 and again braced his elbows on the hatch rim for several hours a day. Needle aspiration of the bursa on 19 July 2012 also preceded the worsening.
Factor 8(10): having surgery to the external elbow of the affected side in the 30 days before the clinical worsening of olecranon bursitis; — MET
- The surgeon at the role 2 facility performed incision and drainage of the left olecranon bursa on 30 July 2012, 21 days before the worsening.
Factor 8(11): for septic olecranon bursitis only, being in an immunocompromised state as specified at the time of the clinical worsening of olecranon bursitis; — MET
- The worsening was septic, and the veteran had chronic myeloid leukaemia and was taking imatinib 400 mg daily on 20 August 2012.
Factor 8(12): having a disorder from the specified list of disorders at the time of the clinical worsening of olecranon bursitis; — MET
- Diabetes, with an HbA1c of 8.3 per cent on 20 August 2012, and gout, with monosodium urate crystals in the bursal aspirate that day, were present at the worsening.
Factor 8(13): having psoriasis, localised sclerosis, atopic dermatitis or another inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected elbow, at the time of the clinical worsening of olecranon bursitis; — MET
- Psoriasis of the left extensor elbow, flared by heat, sweat and friction, was recorded around the drainage wound on 20 August 2012.
Factor 8(14): being treated with a tyrosine kinase inhibitor within the 30 days before the clinical worsening of olecranon bursitis; — MET
- Imatinib 400 mg daily was taken throughout the 30 days before the worsening, from 21 July to 20 August 2012.
Factor 8(15): inability to obtain appropriate clinical management for olecranon bursitis. — MET
- On deployment the septic bursitis was managed with oral antibiotics, repeated aspiration and drainage at a role 2 facility, and the veteran was returned to turret duties that pressed on the elbow within days each time, without rest, splinting or specialist review. The infection recurred as a resistant abscess with spreading cellulitis on 20 August 2012 and the bursitis became chronic. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Olecranon Bursitis, No. 63 of 2018
Causative factors
Factor 8(1): having a bacterial, fungal or algal infection involving the affected bursa at the time of the clinical onset of olecranon bursitis; — MET
- Staphylococcus aureus was grown from the left olecranon bursa aspirated on warlike service in Afghanistan on 19 June 2012, the infection having entered through the laceration sustained in the turret hatch on 02 June 2012.
Factor 8(2): having trauma to the external elbow of the affected side in the 30 days before the clinical onset of olecranon bursitis; — MET
- On warlike service in Afghanistan the veteran lacerated the left elbow on the turret hatch on 02 June 2012, 16 days before onset, and braced, rubbed and knocked his elbows on the hatch rim daily on patrols throughout the 30 days before onset.
Factor 8(3): having surgery to the external elbow of the affected side in the 30 days before the clinical onset of olecranon bursitis; — MET
- The laceration was surgically debrided and sutured at the role 2 facility in Afghanistan on 02 June 2012, 16 days before onset.
Factor 8(4): for septic olecranon bursitis only, being in an immunocompromised state as specified at the time of the clinical onset of olecranon bursitis; — MET
- The bursitis was septic, and throughout his warlike service in Afghanistan the veteran had chronic myeloid leukaemia treated with imatinib, both present at onset on 18 June 2012.
Factor 8(5): having a disorder from the specified list of disorders at the time of the clinical onset of olecranon bursitis; — MET
- Diabetes mellitus and gout were present at onset on warlike service, with diabetic control deteriorating on deployment rations (HbA1c 7.9 per cent in May 2012) and an attack of gout in the right foot in April 2012 attributed to dehydration in the heat of Afghanistan.
Factor 8(6): having psoriasis, localised sclerosis, atopic dermatitis or another inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected elbow, at the time of the clinical onset of olecranon bursitis; — MET
- Psoriasis over the left extensor elbow flared with friction against the hatch rim, heat and sweat on warlike service, and an active plaque was recorded over the left olecranon at onset.
Factor 8(7): being treated with a tyrosine kinase inhibitor within the 30 days before the clinical onset of olecranon bursitis; — MET
- Imatinib 400 mg daily, supplied for his deployment, was taken every day on warlike service in Afghanistan, including the 30 days before onset from 19 May to 18 June 2012.
Worsening factors
Factor 8(8): having a bacterial, fungal or algal infection involving the affected bursa at the time of the clinical worsening of olecranon bursitis; — MET
- Methicillin-resistant Staphylococcus aureus was grown from the recurrent bursal abscess on warlike service in Afghanistan on 20 August 2012, the date of the worsening.
Factor 8(9): having trauma to the external elbow of the affected side in the 30 days before the clinical worsening of olecranon bursitis; — MET
- On warlike service in Afghanistan the bursa was incised on 30 July 2012, and from 04 August 2012 he again braced and rubbed his elbows on the turret hatch rim on patrols, within the 30 days before the worsening.
Factor 8(10): having surgery to the external elbow of the affected side in the 30 days before the clinical worsening of olecranon bursitis; — MET
- Incision and drainage of the left olecranon bursa was performed at the role 2 facility in Afghanistan on 30 July 2012, 21 days before the worsening.
Factor 8(11): for septic olecranon bursitis only, being in an immunocompromised state as specified at the time of the clinical worsening of olecranon bursitis; — MET
- The worsening was septic, and chronic myeloid leukaemia treated with imatinib was present on warlike service at the worsening on 20 August 2012.
Factor 8(12): having a disorder from the specified list of disorders at the time of the clinical worsening of olecranon bursitis; — MET
- Diabetes and gout were present at the worsening on warlike service, with an HbA1c of 8.3 per cent and urate crystals in the bursal aspirate on 20 August 2012.
Factor 8(13): having psoriasis, localised sclerosis, atopic dermatitis or another inflammatory skin disorder, where the skin disorder involves the skin of the extensor surface of the affected elbow, at the time of the clinical worsening of olecranon bursitis; — MET
- Active psoriasis of the left extensor elbow was recorded on warlike service on 20 August 2012.
Factor 8(14): being treated with a tyrosine kinase inhibitor within the 30 days before the clinical worsening of olecranon bursitis; — MET
- Imatinib was taken daily on warlike service in Afghanistan throughout the 30 days before the worsening, from 21 July to 20 August 2012.
Factor 8(15): inability to obtain appropriate clinical management for olecranon bursitis. — MET
- On warlike service in Afghanistan the septic bursitis was treated only with oral antibiotics, aspiration and drainage at a role 2 facility, with return to turret duties within days, and no rest, splinting, intravenous antibiotics or specialist review until the bursitis had recurred as a resistant abscess on 20 August 2012.
The % contribution of the causes is 100% and significant.
Sequelae
The chronic left olecranon bursitis has left a tender bursectomy scar, recurrent swelling with pressure and an olecranon spur, and the recurrent infection required intravenous antibiotics and surgery. These should be considered for acceptance as sequelae.
Unintended Consequence
Met. Imatinib prescribed and paid for by the Commonwealth for the veteran's chronic myeloid leukaemia lowered his immunity and is itself a recognised factor for olecranon bursitis, and the incision and drainage performed by a Defence surgeon on deployment was followed within 21 days by the resistant recurrence. These are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On warlike service in Afghanistan the septic olecranon bursitis of an immunocompromised veteran was managed with oral antibiotics, repeated aspiration and incision and drainage at a role 2 facility, and each time he was returned to crew commander duties that required bracing the elbow on the turret hatch rim within days, without rest, splinting, intravenous antibiotics or orthopaedic review. The infection recurred with methicillin-resistant Staphylococcus aureus, spreading cellulitis and a sinus on 20 August 2012, required aeromedical evacuation and later bursectomy, and the bursitis became chronic. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational demands that prevent rest and definitive treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 Mar 2008, Dermatology consultation, Dermatologist
- 22 Sep 2010, Outpatient health record and pathology, Medical Officer, Garrison health centre
- 07 Apr 2011, Haematology consultation and bone marrow report, Haematologist
- 02 Jun 2012, Wound management record, Surgeon, Role 2 facility, Afghanistan
- 09 Jun 2012, Wound review, Medical Officer, Role 1 facility, Afghanistan
- 19 Jun 2012, Outpatient health record, ultrasound and microbiology report, Medical Officer, Role 2 facility, Afghanistan
- 30 Jul 2012, Procedure record, incision and drainage, Surgeon, Role 2 facility, Afghanistan
- 20 Aug 2012, Aeromedical evacuation and inpatient record, Role 3 hospital, Afghanistan
- 28 Sep 2012, X-ray left elbow report, Radiologist
- 14 Nov 2012, Operation report and histopathology, bursectomy, Orthopaedic surgeon
- Statement of Principles concerning Olecranon Bursitis (Balance of Probabilities) No. 64 of 2018, Repatriation Medical Authority
- Statement of Principles concerning Olecranon Bursitis (Reasonable Hypothesis) No. 63 of 2018, Repatriation Medical Authority
