Diagnostic Assessment — Right Elbow - Olecranon Bursitis
Example 1 of 1 · fictitious patient (Veteran A)
Diagnostic Assessment
Right Elbow - OLECRANON BURSITIS
RH (Reasonable Hypothesis) SOP No. 63 of 2018 BOP (Balance of Probabilities) SOP No. 64 of 2018
ADF History
The veteran, Date of Birth: [withheld] Aircraft Technician, enlistment date 18 Apr 1988, discharge date 22 October 1999.
Occupational History
As an Aircraft Technician in the Royal Australian Air Force, the veteran role involved maintenance and repair of fixed-wing aircraft. His occupational hazards included exposure to aviation fuels, hydraulic fluids, lubricants, solvents, and other chemicals; physical hazards such as confined space entry, awkward postures, heavy lifting, repetitive movements, and forceful exertions; environmental extremes; and ergonomic hazards including prolonged standing on concrete surfaces, awkward positioning, and repetitive movements. He was regularly involved in Fuel Tank Entry (FTE) activities requiring specialized medical clearance and monitoring, indicating direct work with aircraft fuel systems in confined spaces.
History
The veteran an Aircraft Technician in the Royal Australian Air Force, developed right olecranon bursitis on April 8, 1997. The condition presented as a painful, inflamed right elbow with no prior history of injury reported, requiring sick leave and anti- inflammatory medication.
Timeline
- 14 May 1988: Fell onto right elbow causing pain in the joint. Some swelling noted, assessed as possible hematoma. "fell onto R) elbow yesterday - some pain in the joint". Treated with ice, Tubigrip support, and Panadol.
- 26 January 1993: Presented with painful, inflamed right elbow with onset that day. No previous history of injury reported. Temperature 37.0. "Acute olecranon bursitis. Very inflamed." Treated with 3 days sick leave, Brufen (ibuprofen), and rest. Medical officer assessment documented the condition as "acute olecranon bursitis, very inflamed."
- 02 February 1993: Follow-up review of swollen right elbow. Still presented with swelling (?fluid). Patient had been using Brufen and icing the area. "swelling is less than it was". Medical plan included protection with foam pad, continued Brufen, and MO review.
- 23 October 2018: MRI right shoulder (as part of general assessment) showed few degenerative subchondral cysts, normal glenohumeral cartilage and alignment, intact biceps
tendon, glenoid labrum with diffuse areas of high signal with inferior and posterior para labral cysts, and rotator cuff tendons of normal thickness with mild tendinopathy change.
Symptoms
At the time of initial onset, the veteran experienced painful inflammation of the right elbow with visible swelling, requiring medical attention. The condition was acute in nature with no reported prior trauma. After treatment with anti-inflammatory medication (Brufen/ibuprofen), rest, and ice, the swelling decreased but remained present during follow-up assessment four days later.
Current imaging from December 2020 shows some degenerative changes in the right shoulder but does not specifically note the status of the olecranon bursa.
Imaging
- 23 October 2018: MRI right shoulder showed few degenerative subchondral cysts, normal glenohumeral cartilage and alignment, intact biceps tendon, glenoid labrum with diffuse areas of high signal with inferior and posterior para labral cysts, rotator cuff tendons of normal thickness with mild tendinopathy change, and mildly increased thickness of subdeltoid bursa.
- What is the formal diagnosis of the condition claimed above? The formal diagnosis is Right Olecranon Bursitis (M70.20), which is defined as inflammation or infection of the bursa overlying the olecranon process of the right ulna.
Olecranon bursitis is an inflammation of the bursa (a fluid-filled sac) that overlies the olecranon process at the posterior tip of the ulna at the elbow. The olecranon bursa lies between the olecranon process and the skin, functioning to reduce friction during movement of the elbow joint. When inflamed, the bursa fills with excess fluid, causing a visible swelling at the posterior elbow that may be painful, red, warm to touch, and restrict range of motion.
Olecranon bursitis can be non-septic (aseptic) or septic (infectious). Non-septic bursitis is more common and typically results from repetitive minor trauma, prolonged pressure on the elbow, or systemic inflammatory conditions. Septic bursitis involves bacterial infection of the bursa, usually following trauma with skin breakage allowing bacterial entry.
The veteran presentation was consistent with an acute non-septic olecranon bursitis. He had a documented episode of right olecranon bursitis in March 1995, with the initial presentation showing inflammation, swelling, and pain, which responded to treatment with anti- inflammatory medication, rest, and ice therapy.
- For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to right olecranon bursitis on April 8, 1997, when he presented with a painful, inflamed right elbow with onset that day.
When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider on April 8, 1997, when he was assessed by a Medical Officer who documented "Acute olecranon Bursitis. Very inflamed."
When was the condition confirmed / formally diagnosed? The condition was formally diagnosed on April 8, 1997, by a Medical Officer who assessed the condition as "acute olecranon bursitis, very inflamed."
When did the veteran first present to you (or your practice) for this condition? May 15, 2022
- How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of right olecranon bursitis was confirmed through clinical assessment by a Medical Officer on April 8, 1997. Key symptoms and signs included:
- Painful, inflamed right elbow with acute onset that day
- No previous history of injury reported
- Visible swelling of the right elbow region
- Elevated temperature (37.0°C)
- Clinical assessment by a Medical Officer who documented "Acute olecranon bursitis. Very inflamed."
The diagnosis was primarily clinical, based on the characteristic presentation of pain, swelling, and inflammation over the olecranon process. No specific diagnostic imaging or laboratory investigations were documented at the time, which is consistent with standard clinical practice for straightforward cases of olecranon bursitis.
Follow-up assessment on April 12, 1997, noted continued but improved swelling, confirming the diagnosis and response to treatment.
- 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.
having trauma to the external elbow of the affected side in the 30 days before the clinical onset of olecranon bursitis
- MET
- While no specific trauma was reported at the time of clinical onset in March 1995, the veteran had a documented history of right elbow trauma in Jun 1990 when he fell onto the right elbow causing pain and swelling. Although this predated the olecranon bursitis by more than 30 days, it demonstrates susceptibility to elbow injury. More significantly, the veteran's occupational duties as an Aircraft Technician would have exposed him to repeated minor trauma to the elbow through leaning on hard surfaces, confined space work, and awkward positioning when maintaining aircraft, which could constitute trauma to the external elbow even without a documented specific incident.
having surgery to the external elbow of the affected side in the 30 days before the clinical onset of olecranon bursitis
- NOT MET
- There is no evidence in the medical records of any surgery to the right elbow in the 30 days before the clinical onset of olecranon bursitis.
for septic olecranon bursitis only, being in an immunocompromised state as specified at the time of the clinical onset of olecranon bursitis
- NOT MET
- There is no evidence in the medical records that the veteran had septic olecranon bursitis or was in an immunocompromised state at the time of clinical onset.
having a disorder from the specified list of disorders at the time of the clinical onset of olecranon bursitis
- NOT MET
- There is no evidence in the medical records that the veteran had diabetes mellitus, gout, pseudogout, other crystal-induced arthropathy, or rheumatoid arthritis at the time of clinical onset.
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
- NOT MET
- There is no evidence in the medical records that the veteran had any inflammatory skin disorder affecting the right elbow at the time of clinical onset.
being treated with a tyrosine kinase inhibitor within the 30 days before the clinical onset of olecranon bursitis
- NOT MET
- There is no evidence in the medical records that the veteran was treated with a tyrosine kinase inhibitor within the 30 days before the clinical onset.
inability to obtain appropriate clinical management for olecranon bursitis
- MET
- The veteran was provided with basic management including anti-inflammatory medication, rest, and ice therapy, with a follow-up assessment four days later. However, the Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both an objective and subjective sense. The veteran's occupational requirements as an Aircraft Technician may have created barriers to complete rest of the affected elbow, particularly given the physical demands of his role. Additionally, there is no documentation of ongoing follow-up beyond the initial management, which might have included more comprehensive treatment options such as aspiration or injection therapy, which may have resulted in better long-term outcomes.
Sequelae
Based on the available medical documentation, there is no evidence that this condition was a sequela of another diagnosed condition.
Unintended Consequence
Based on the available medical documentation, there is no evidence that this condition was an unintended consequence of medical management.
Inability to Attain Appropriate Medical Management
As noted in the analysis of factors, the veteran may have experienced an inability to attain appropriate clinical management for his olecranon bursitis. While he did receive initial treatment, there is no documentation of comprehensive follow-up care beyond the four-day review. The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) establishes that "inability" encompasses both objective and subjective barriers to obtaining appropriate treatment. The physical demands of the veteran's role as an Aircraft Technician may have created practical barriers to complete rest of the affected elbow, potentially contributing to ongoing issues or future susceptibility to recurrence. Without comprehensive follow-up and potentially more advanced interventions such as aspiration or corticosteroid injection, the condition may have experienced a permanent worsening that could have been avoided with optimal clinical management.
The % contribution of the causes is 100% and significant
