Bursitis

By admin On Nov 24, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Bursitis

Sandeep Johar

Basics

Alert

May be difficult to distinguish from fractures. Suspicious joints should be immobilized, particularly in the setting of trauma.
Inflammation or irritation of the bursa (a sac filled with lubricating fluid, located between tissues such as bone, muscle, tendons, and skin, which decreases rubbing, friction, and irritation)
Potentially any bursa may be affected:
- Subacromial (subdeltoid) bursitis: Lies between the acromion and the rotator cuff
- Olecranon bursitis: Lies between the olecranon process and the overlying skin (usually secondary to trauma)
- Iliopsoas bursitis: Lies between the iliopsoas tendon and the lesser trochanter (largest bursa in the body)
- Trochanteric bursitis: Has superficial and deep components. The superficial bursa lies between the tensor fascia lata and skin; the deep bursa is located between the greater trochanter and the tensor fascia lata.
- Prepatellar bursitis: Lies between the patella and the skin (usually secondary to trauma or frequent forward kneeling)
- Calcaneal bursitis: 2 bursae at the level of insertion of the Achilles tendon. The superficial one is located between the skin and the tendon, and the deep one is located between the calcaneus and the tendon.

Description

Bursae are flattened sacs that serve as a protective buffer between bones and overlapping muscles (deep bursae) or between bones and tendons/skin (superficial bursae). In the normal state, they contain minimal amounts of fluid to reduce friction and facilitate pain-free movement during muscle contraction.
Humans have ∼160 bursae.

Risk Factors

If you work in a profession or have a hobby that requires repetitive motion or pressure on particular bursae (ie, carpet laying, tile setting, gardening, bicycling, baseball, ice skating)
Rheumatoid arthritis
Osteoarthritis
Gout
Thyroid disease
Diabetes

Etiology

Trauma (acute and chronic): Most common cause
Septic bursitis: Direct introduction of microorganisms through traumatic injury or through contiguous spread from cellulitis
Predisposing factors for septic bursitis include diabetes, alcoholism, steroid therapy, uremia, trauma, and skin disease.
For septic bursitis: Staphylococcus aureus causes 80%, followed by Streptococcus
Crystal deposition: Gout or pseudogout
Systemic diseases: Rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, scleroderma, systemic lupus erythematosus, pancreatitis, Whipple disease, oxalosis, uremia, hypertrophic pulmonary osteoarthropathy, idiopathic hypereosinophilic syndrome

Diagnosis

Full assessment of regional musculoskeletal function
Any suspicion of infection warrants aspiration of bursae (especially olecranon and prepatellar bursae)
Aspiration of hip and other deep bursae should be deferred to orthopedics or rheumatology, or may be guided in emergency department by US

Physical Exam

Localized tenderness
Decreased range of motion or pain with movement
Erythema or edema (seen in superficial bursitis)
Traumatic bursitis often follows traumatic event or overuse of related joints.

Diagnostic Tests & Interpretation

Lab

CBC with differential, erythrocyte sedimentation rate, serum protein electrophoresis, rheumatoid factor, serum uric acid
Aspiration and analysis of bursa fluid: Cell count with differential, glucose and total protein, crystal determination, gram stain, and culture
Normal fluid: Fluid is clear yellow with 0–200 WBCs, 0 RBCs, low protein, and glucose is same as serum.
Traumatic bursitis: Fluid is bloody/xanthochromic with <1,200 WBCs, many RBCs, low protein, and normal glucose.
Infective bursitis: Fluid is cloudy yellow with >50,000 WBCs, few RBCs, slightly increased protein, and decreased glucose; bacteria on gram stain.

P.57

Rheumatoid and microcrystalline inflammation: Fluid is yellow, can be cloudy, and has 1,000–40,000 WBCs, few RBCs, slightly increased protein, and variable glucose; use polarizing microscope to identify crystals.
Chronic or recurrent bursitis should be sent for acid-fast staining and cultured on special media for mycobacteria, Brucella, and algae.
Monosodium urate crystals seen in gout; calcium pyrophosphate crystals seen in pseudogout

Imaging

X-rays to exclude other suspected pathologies (ie, fractures, dislocations)
X-rays may demonstrate chronic arthritic changes or calcium deposits
US for diagnostic aspiration or treatment injections
MRI helps depict bursa/prebursa fluid, associated abscesses, and adjacent soft tissue structures.

Differential Diagnosis

Arthritis: Rheumatoid, septic, osteo-
Cellulitis
Gout and pseudogout
Fracture, tendon/ligament tear, contusion, sprain
Tendonitis

Treatment

ED Treatment

Shoulders should not be immobilized for more than 2–3 days due to the risk of adhesive capsulitis.
Aseptic bursitis: Rest, ice, compression, elevation, NSAIDs, bursa aspiration, and intrabursa steroid injections
Septic bursitis: If suspected, treat with antibiotics while awaiting culture results and drain bursae.
Superficial septic bursitis can be treated with oral therapy.
Septic bursitis with systemic symptoms or who are immunocompromised require IV antibiotics.
Staphylococcus aureus 80%, followed by streptococcal species
Penicillinase-resistant penicillin (oxacillin) or 1st-generation cephalosporin (cefazolin). In penicillin-allergic patients or in carriers of methicillin-resistant Staphylococcus aureus, vancomycin

Medication

NSAIDs: Ibuprofen: Adult: 800 mg PO q8h; peds: 10 mg/kg PO q8h. Naproxen: Adult: 250–500 mg PO b.i.d. Ketorolac: Adult: 30 mg IV/IM q6h or 10 mg PO q4–6h
Most patients may be treated as an outpatient.
Antibiotics (for an infected bursitis): Oxacillin: Adult: 500–1,000 mg PO q4–6h, 1–2 g IV/IM q6h; peds: 50–100 mg/kg/day PO divided q6h, 150–200 mg/kg/day IV/IM divided q6h Cefazolin: Adult: 2 g IM/IV; peds: 20 mg/kg IM/IV. Vancomycin: Adult: 1 g IV q12h; peds: 10–15 mg/kg IV q6h

Surgery/Other Procedures

In general, bursitis is not treated surgically. However, surgical release may be indicated when adhesive bursitis develops, severely limiting joint motion. During surgery, the adhered bursa is removed and the contiguous tissues are released.

In-Patient Considerations

Initial Stabilization

Immobilize joint if pain is severe.

Admission Criteria

Septic bursitis with high fevers, surrounding cellulitis, unable to take oral antibiotics, failed outpatient therapy, or immunocompromised

Ongoing Care

Follow-Up Recommendations

Most patients respond to therapy within 1 wk.
Rheumatology or orthopedic referral is recommended for patients with repetitive acute bouts, necessitating repeated joint/bursa aspirations or, eventually, surgical excision of involved bursa.

Additional Reading

Costantino TG, Roemer B, Leber EH. Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis. J Emerg Med. 2007;32(3):295–297.

Torralba KD, Quismorio FP Jr. Soft tissue infections. Rheum Dis Clin North Am. 2009;35(1):45–62.

Valeriano-Marcet J, Carter JD, Vasey FB. Soft tissue disease. Rheum Dis Clin North Am. 2003;29(1):77–88, vi.

Codes

ICD9

726.19 Other specified disorders of bursae and tendons in shoulder region
726.33 Olecranon bursitis
727.3 Other bursitis disorders