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Olecranon Bursitis

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Other Names

  • Septic Olecranon Bursitis
  • Infectious Olecranon Bursitis
  • Aseptic Olecranon Bursitis
  • Noninfectious Olecranon Bursitis
  • Sterile Olecranon Bursitis

Background

  • This page to inflammatory process of the Olecranon Bursa of the of Elbow
    • Can be aseptic (non-infectious), septic (infectious) or chronic
    • Aseptic and septic can be difficult to distinguish with considerable overlap

History

Epidemiology

  • Incidence and frequency likely under-reported as many cases are self limited
  • Smith et al: 3/1000 emergency department visits, 1 of 3-4 cases is septic[1]
  • Septic bursitis is more common in middle aged men[2]
  • Overall more common in summer months[3]

Pathophysiology

Anatomy of the olecranon bursa[4]
Long and short axis ultrasound images of olecranon bursitis[5]

Etiology

  • Acute[6]
    • Direct trauma most common[7]
    • Prolonged pressure
  • Chronic
    • Recurrent acute episodes
    • Occupational or prolonged recreational episodes
    • Secondary to systemic disorders
  • Septic Bursitis
    • Almost always related to direct trauma[8]
    • Direct inoculation from skin wound, local cellulitis[9]
    • Rarely, Hematogenous spread[10]

Pathoanatomy

  • Bursae are fluid filled sacks that minimize friction and facilitate gliding of overlapping structures[11]
  • The olecranon bursa represents a superficial bursa located between the deep surface of the Triceps Brachii anatomy and bony Olecranon

Microbiology

  • Most common causes of septic bursitis[11]
    • #1 Staphylococcus aureus
    • #2 Beta-hemolytic Streptococcus

Risk Factors

Differential Diagnosis

Clinical Features

  • History
    • Generally will report a history of trauma
    • Will complain of pain, swelling, redness
  • Physical: Physical Exam Elbow
    • Both septic and nonseptic olecranon bursitis can present with bursa swelling, redness, and pain to palpation[14]
    • Pain with elbow motion
    • Range of motion should be preserved (extra-articular disease)
  • Septic Arthritis
    • when considering septic arthritis, the clinician needs to strongly consider risk factors as noted above
      • Review: comorbidities, risk factors, recent medication use, history, trauma, occupation, hobbies, etc
    • The presence of lacerations and abrasions is not sensitive for identifying septic cases (need citation)
    • Fever is seen between 20% and 77% of cases, depending on the study referenced[11]

Evaluation

  • Difficult to differentiate nonseptic olecranon bursitis from septic olecranon bursitis
MRI of chronic appearing olecranon bursitis
Ultrasound of posterior elbow demonstrating fluid collection in the bursa

Radiographs

  • Standard Radiographs Elbow
  • Xray can help evaluate for any loose body within the elbow and evaluate for other pathology
  • Bursitis will present as concentric circles in AP view and lateral view
  • Septic bursitis can present with a joint effusion, including a posterior fat pad sign
    • This can be sterile or infectious[15]
  • Olecranon spurs asre associated with olecranon bursitis[16]

MRI

  • Only needed if concern for osteomyelitis or abscess

Ultrasound

  • Findings
    • Soft tissue swelling, cobblestoning may be seen in septic bursitis
    • Fluid collection within the bursa

Aspiration

  • General
    • If suspicious of septic arthritis, aspiration is indicated
    • Gold standard for diagnosing septic arthritis is a positive culture of bursal fluid, however not helpful in deciding to initiate treatment[17]
    • Send fluid for gram stain, culture, cell count, crystal analysis, glucose, protein
  • Findings
    • Gram stain unreliable, only positive between 50-100% of time in culture positive cases[18]
    • WBC: unreliable, ranging from 690-418,000 cells/mm3 in septic cases, between 50-10,000 cells/mm3 in aseptic cases
    • Differential: Favors PMN in septic cases, monocytes in aseptic cases[19]
    • Bursal glucose <50% of serum glucose favors septic bursitis, however not reliable[20]
    • Comparing skin temperature with a difference of 2.2°C between affected limb and unaffected limb is 100% sensitive, 94% specific[21]
    • Blood can be tested for CBC, CRP, ESR, glucose
    • Blood cultures are controversial, bacteremia ranges from 4-30% and depends on comorbidities and risk factors[22]

Classification

  • N/A

Management

Prevention

  • Avoid triggering activity is best treatment
  • In occupational cases, ergonomics and proper bracing may be helpful

Nonoperative

  • Management is based on etiology of the bursitis
  • Noninfectious or aseptic
    • Activity modification
    • Elbow Compression Sleeve, preferably with padding
    • NSAIDS
    • Typically managed conservatively
    • Corticosteroid injection increases risk of septic bursitis and formation of sinus tract[23]
      • Increased risk of septic bursitis, skin atrophy
    • Initial aspiration is only recommended if septic bursitis is expected. In cases where the patient clearly has noninfectious bursitis, aspiration increases risk of infection.
    • Consider Physical Therapy in refractory cases
  • Septic bursitis
    • Aspirate and drain bursa, although drainage is considered controversial without any reported improvement in outcomes[24]
    • Antibiotics that cover for Staph Aureus and beta-hemolytic strep[25]
    • Average length of treatment is 10-14 days, less may be insufficient[26]
    • Consider community acquired MRSA coverage (Clindamycin, Bactrim, Doxycycline)

Operative

  • Noninfectious Bursitis
    • Indicated when conservative management fails, although clear guidelines on failure
    • Technique: Olecranon Bursectomy
    • Notorious for wound healing complications[27]
  • Septic Bursitis
    • No clear advantage to surgical management over aspiration or incision and drainage
    • Indications[28]
      • Inadequate needle aspiration due to thick pus or loculations
      • Presence of a pointing abscess or foreign body
      • Refractory disease
      • Need to investigate the extent of the infection

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Aseptic bursitis
    • Uncomplicated cases can return when asymptomatic with full elbow range of motion
  • Septic Bursitis
    • At discretion of physician

Complications

  • Non-surgical
    • Recurrent symptoms
    • Recurrent infection
  • Surgical
    • Poor wound healing

See Also

References

  1. ↑ Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Septic and Nonseptic Olecranon Bursitis: Utility of the Surface Temperature Probe in the Early Differentiation of Septic and Nonseptic Cases. Arch Intern Med. 1989;149(7):1581–1585. doi:https://doi.org/10.1001/archinte.1989.00390070101015
  2. ↑ . Ho G Jr, Tice AD, Kaplan SR. Septic bursitis in the prepatellar and olecranon bursae: an analysis of 25 cases. Ann Intern Med 1978;89: 21-7
  3. ↑ . Laupland KB, Davies HD. Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home parenteral therapy program study group. Clin Invest Med 2001;24:171-8.
  4. ↑ Image courtesy of https://www.rehabmypatient.com/, "Elbow (olecranon) bursitis"
  5. ↑ Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  6. ↑ Reilly, Danielle, and Srinath Kamineni. "Olecranon bursitis." Journal of shoulder and elbow surgery 25.1 (2016): 158-167.
  7. ↑ . Canoso JJ, Yood RA. Reaction of superficial bursae in response to specific disease stimuli. Arthritis Rheum 1979;22:1361-4.
  8. ↑ McAfee JH, Smith DL. Olecranon and prepatellar bursitis. Diagnosis and treatment. West J Med 1988;149:607-10.
  9. ↑ Larson RL, Osternig LR. Traumatic bursitis and artificial turf. J Sports Med 1974;2:183-8.
  10. ↑ Garcia-Porrua C, Gonzalez-Gay MA, Ibanez D, Garcia-Pais MJ. The clinical spectrum of severe septic bursitis in northwestern Spain: a 10 year study. J Rheumatol 1999;26:663-7.
  11. ↑ 11.0 11.1 11.2 Reilly JP, Nicholas JA. The chronically inflamed bursa. Clin Sports Med 1987;6:345-70.
  12. ↑ . Laupland KB, Davies HD. Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home parenteral therapy program study group. Clin Invest Med 2001;24:171-8.
  13. ↑ Frank Floemer, W. M. (2004). MRI characteristics of olecranon bursitis. American Journal of Roentgenology, 29-34
  14. ↑ Danielle Reilly, S. K. (2016). Olecranon Bursitis. Journal of Shoulder and Elbow Surgery, 158-167.
  15. ↑ . Ho G Jr, Tice AD. Comparison of nonseptic and septic bursitis. Further observations on the treatment of septic bursitis. Arch Intern Med 1979;139:1269-73.
  16. ↑ . Saini M, Canoso JJ. Traumatic olecranon bursitis. Radiologic observations. Acta Radiol Diagn (Stockh) 1982;23:255-8.
  17. ↑ Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med 2009;37: 269-72.
  18. ↑ . McAfee JH, Smith DL. Olecranon and prepatellar bursitis. Diagnosis and treatment. West J Med 1988;149:607-10.
  19. ↑ . Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Septic and nonseptic olecranon bursitis. Utility of the surface temperature probe in the early differentiation of septic and nonseptic cases. Arch Intern Med 1989;149:1581-5.
  20. ↑ Garcia-Porrua C, Gonzalez-Gay MA, Ibanez D, Garcia-Pais MJ. The clinical spectrum of severe septic bursitis in northwestern Spain: a 10 year study. J Rheumatol 1999;26:663-7.
  21. ↑ 4. Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med 1989;149:2527-30.
  22. ↑ . Roschmann RA, Bell CL. Septic bursitis in immunocompromised patients. Am J Med 1987;83:661-5
  23. ↑ Philip Weinstein, J. C. (1984). Long-term follow up of corticosteroid injection for traumatic olecranon bursitis. Annals of the Rheumatic Diseases, 44-46.
  24. ↑ Laupland KB, Davies HD. Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home parenteral therapy program study group. Clin Invest Med 2001;24:171-8.
  25. ↑ Eli Sayegh, R. S. (2014). Treatment of olecranon bursitis: a systematic review. Archives of Orthopedic and Trauma Surgery, 1517-1536.
  26. ↑ . Ho G Jr, Su EY. Antibiotic therapy of septic bursitis. Its implication in the treatment of septic arthritis. Arthritis Rheum 1981;24:905-11.
  27. ↑ . Larson RL, Osternig LR. Traumatic bursitis and artificial turf. J Sports Med 1974;2:183-8.
  28. ↑ 51. Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum 1995;24:391-410.
Created by:
John Kiel on 10 June 2019 17:07:44
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Last edited:
30 October 2023 14:55:35
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