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Olecranon Bursitis

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Ovid: 5-Minute Sports Medicine Consult, The


Olecranon Bursitis
Catherine Rainbow
Robert L. Jones
Basics
Description
  • Inflammation of the superficial olecranon bursa
  • 3 different types of olecranon bursitis exist: acute, chronic, and septic.
    • Acute:
      • Caused by direct trauma to the bursa
      • Usually hemorrhagic bursitis that causes swelling within a few hours
      • Often seen in sports such as football, wrestling, and volleyball
    • Chronic:
      • Most common form of olecranon bursitis
      • Due to repetitive trauma or rubbing of the bursa
      • Bursal linings become thickened by fibrosis.
      • Also may be caused by systemic inflammatory processes (eg, rheumatoid arthritis) or crystal deposition disease
    • Septic:
      • Superimposed infection of acute or chronic olecranon bursitis
      • Develops from skin wounds, dermatitis, or hematogenous seeding
  • Synonym(s): Miner's elbow; Student's elbow
Risk Factors
  • Acute: Direct elbow trauma
  • Chronic:
    • Multiple episodes of elbow trauma
    • Illnesses that cause crystal deposition or systemic inflammatory conditions
  • Septic:
    • History of elbow trauma
    • Skin lesions
General Prevention
  • High-quality elbow pads
  • Softer playing surfaces (natural turf)
  • Avoiding repetitive elbow motions
Etiology
  • Acute:
    • Synovial cell inflammatory response following direct trauma to the bursa
    • Hemorrhagic fluid collects in the bursa from capillary destruction.
  • Chronic:
    • Synovial cell inflammatory response to repetitive microtrauma of the bursa
    • May be associated with systemic inflammatory processes or crystal deposition disease
  • Septic:
    • Synovial cell and systemic inflammatory response to an infectious agent
    • Infectious agent is either inoculated directly into the bursa via trauma or arrives by hematogenous spread.
    • Polymorphonuclear cells infiltrate the infected bursa.
    • May be more likely to occur in immunocompromised patients
Diagnosis
History
  • Acute:
    • History of recent direct trauma to the elbow
    • Rapid swelling and pain
  • Chronic:
    • Multiple episodes of elbow trauma
    • Certain occupations requiring repetitive pressure to the bursa (eg, carpenters)
    • Chronic swelling
  • Septic:
    • Likely history of superficial elbow trauma
    • Swelling and erythema of the bursa (overlying cellulitis or peribursal cellulitis)
    • Pain over the olecranon bursa with range of motion and palpation
    • May have systemic symptoms such as fever
Physical Exam
  • All forms present with a swollen, fluctuant fluid collection of the superficial olecranon bursa.
  • Acute:
    • Afebrile
    • Tenderness to palpation of the bursa
    • Preserved range of motion
  • Chronic:
    • Afebrile
    • Nontender to palpation
    • Preserved range of motion
    • Fibrotic trabeculae and villi may form a SC mass that is palpable.
  • Septic:
    • Often tender along the olecranon bursa ± elbow motion
    • Overlying skin abrasions and erythema often present
    • Possible systemic symptoms such as fever
    • If complicated, may have decreased range of motion of the elbow
Diagnostic Tests & Interpretation
Lab
  • Acute: No labs indicated
  • Chronic:
    • Assess for systemic inflammatory diseases such as rheumatoid arthritis with a rheumatoid factor, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
    • Assess for gout with uric acid level or crystal analysis of the bursal fluid (1)[C].
  • Septic:
    • Assess for infection with a CBC with differential, ESR, and CRP (1)[C].
    • Perform diagnostic bursal aspiration, and send fluid for Gram stain, crystals, cell count, and culture (2)[C].
    • Perform a blood culture to rule out sepsis if systemic symptoms are present.
Imaging
  • Plain films of the elbow should be obtained to rule out fracture and/or dislocation, especially if trauma precipitated olecranon bursitis.
  • US may be helpful to assess integrity of the triceps tendon, and it may demonstrate inflammation of the olecranon bursa.
  • Sonography also may be helpful during aspiration if fluid is loculated.
  • MRI is used as a last resort to rule out other pathology, including triceps tear, tendinopathy, and/or stress fractures.
Diagnostic Procedures/Surgery
  • Acute:
    • Aspiration of bursa is not a necessary procedure but is helpful for athletes attempting to return to play (3)[C].
    • Hemorrhagic fluid is usually aspirated.
  • Chronic:
    • Aspiration of bursa is not a necessary procedure but is often done for patient comfort, aesthetics, and return to play.
    • Aspirated synovial fluid may show crystals, as seen in gout or pseudogout.
    • Steroid injection via the lateral approach followed by a light compression dressing is controversial (3)[C].
    • Must be performed after bursal fluid aspiration
    • More recent studies suggest that steroid injections facilitate healing and decrease recurrence (3)[C].
  • Septic:
    • Must aspirate synovial fluid from the olecranon bursa for Gram stain and culture to identify the infectious agent (4,5)[C]
    • Purulent fluid obtained
    • Never perform a steroid injection in a suspected infected olecranon bursa.
Pathological Findings
  • Acute:
    • Hemorrhagic synovial fluid
    • WBC count between 2,000 and 100,000 WBCs/µL consistent with inflammatory response (1)[C]
    • Negative Gram stain and culture
  • Chronic:
    • Possible crystals owing to gout or pseudogout
    • WBC count ranges depending on whether the patient has a systemic inflammatory disease.
    • Negative Gram stain and culture
  • Septic:
    • Purulent synovial fluid
    • WBC count >100,000 WBCs/µL (1)[C]
    • Positive/negative Gram stain with positive culture

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Differential Diagnosis
  • Cellulitis
  • Fracture of the olecranon process of the ulna
  • Osteoarthritis
  • Septic arthritis
  • Overuse injury of the elbow
  • Ligamentous injury
  • Triceps avulsion, tear, or tendinitis
  • Triceps enthesopathy owing to chronic tendinosis
  • Contusion
  • Gout and pseudogout
  • Systemic inflammatory disease such as lupus and rheumatoid arthritis
  • Synovial cyst of the elbow joint
Treatment
  • Ice
  • NSAIDs
  • Compression
  • Elevation
  • Avoidance of repetitive elbow movements
  • Frequent monitoring
  • Aspiration:
    • Perform when distension causes significant discomfort and loss of motion (2)[C].
    • Always perform on painful bursa with suspected infection. Fluid should be analyzed for cell count, crystals, Gram stain, and culture.
    • Aseptic fluid typically is straw-colored, whereas septic fluid is purulent.
    • Staphylococcus aureus is the most common organism detected in septic bursitis (4)[C].
    • Perform aspiration through healthy, intact skin so as to not cause an iatrogenic infection.
  • Steroid injections (5)[C]:
    • Always aspirate bursal fluid prior to steroid injection.
    • Used by some clinicians for acute and chronic bursitis with mixed results; may decrease healing time and recurrences (3)[C]
    • Contraindicated if infection suspected
  • Antibiotics:
    • Antibiotics are given when septic bursitis is suspected.
      • Must aspirate bursal fluid prior to initiation of antibiotic therapy for cell count, Gram stain, and culture
      • Typically cover for S. aureus and streptococci, but treatment is usually directed by Gram stain and culture results (4)[C].
        • If no systemic illness is identified, may proceed with oral antibiotics for 4 wks (4)[C]
        • If systemic illness is identified, one must initiate therapy with IV antibiotics followed by oral antibiotics for a total of 4 wks of antibiotic therapy (4)[C].
  • Incision and drainage: May be needed in some cases of septic bursitis
  • Surgery: Bursectomy is performed for refractory cases that limit activity.
Medication
  • NSAIDs: May use NSAID of choice
  • Antibiotics:
    • IV antibiotics if systemic symptoms present initially; then switch to oral antibiotics based on culture results for a 4-wk course of therapy (4)[C].
    • Suggested empirical IV therapy: Oxacillin 2 g IV q6h (3)[C]
    • Oral antibiotics for 4 wks if no systemic signs are present (4)[C]
    • Suggested empirical oral therapy:
      • Oxacillin 500 mg PO q6h (3)[C] or
      • Dicloxacillin 1 g q6h with 2 g probenecid daily (3)[C]
    • Cover for S. aureus and streptococci:
      • Usually a penicillinase-resistant penicillin such as oxacillin or cefazolin
      • May include MRSA coverage if patient is immunocompromised
    • In refractory cases, consider TB and Brucella as rare causative agents (4)[C].
    • Immunocompromised patients often will require longer antibiotic treatment (4)[C].
Additional Treatment
Referral
  • Chronic:
    • Consider rheumatology consultation if systemic inflammatory disease is identified.
    • Consider orthopedic surgery consultation if refractory bursitis for bursectomy.
  • Septic: Consider surgical evaluation if systemic symptoms persist despite antibiotic treatment.
Additional Therapies
Physical therapy may benefit patients who have undergone a bursectomy.
Surgery/Other Procedures
Bursectomy may be needed for cases of refractory bursitis or for patients with persistent septic bursitis despite antibiotic therapy.
In-Patient Considerations
Septic: Patients with systemic symptoms such as fever must be hospitalized to receive IV antibiotics.
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
  • Patient follow-up guidelines have not been established.
  • Follow-up for patients with septic bursitis should be frequent to ensure that no complications such as septic arthritis develop.
Patient Education
  • Use NSAIDs regularly if no contraindications.
  • Ice the bursa frequently.
  • Use a light compression stocking over the bursa initially.
  • Elevate the elbow.
  • Avoid repetitive elbow motions.
  • Contact a physician if systemic symptoms develop.
Prognosis
  • Very good
  • Most cases of aseptic olecranon bursitis respond very well to conservative treatment.
  • Some recurrence may be seen, especially after repeated trauma.
  • Septic olecranon bursitis resolves in most cases when treated with appropriate antibiotics.
  • Severe cases of infection and refractory cases of bursitis often require bursectomy, which has good postoperative results.
Complications
  • Can develop chronic olecranon bursitis with repetitive injuries
  • Rarely develop chronic pain at olecranon bursa (1)[C]
  • Complications of a corticosteroid injection include bleeding, bruising, infection, skin atrophy, allergic reactions, and hyperglycemia in diabetic patients (1)[C].
References
1. Foye PM, Stitik TP, Nadler SF. Olecranon bursitis. emedicine. Medscape. Updated March 27, 2009. http://emedicine.medscape.com/article/97346-overview.
2. Deu RS, Carek PJ. Common sports injuries: upper extremity injuries. Clinics in Family Practice. 2005;7:249–265.
3. Salzman KL, Lillegard WA, Butcher JD. Upper extremity bursitis. Am Fam Physician. 1997;56:1797–1806,1811–1812.
4. Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am. 2005;19:991–1005, xi.
5. McFarland EG, Gill HS, Laporte DM, et al. Miscellaneous conditions about the elbow in athletes. Clin Sports Med. 2004;23:743–763, xi–xii.
Codes
ICD9
726.33 Olecranon bursitis
Clinical Pearls
  • Olecranon bursitis is usually caused by some form of trauma to the elbow.
  • Treatment includes NSAIDs, ice, compression, elevation, and therapeutic aspiration for comfort.
  • The bursa must be aspirated if there is concern for infection and the fluid sent for cell count, crystals, Gram stain, and culture.
  • Patients with suspected septic bursitis need to be started on antibiotic therapy with S. aureus and streptococcal coverage until culture results are obtained.
  • Most cases of olecranon bursitis resolve with appropriate therapy, but refractory cases may require a bursectomy.


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