3. Olecranon Bursitis

Olecranon Bursitis

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonym: student's elbow

The olecranon bursa lies over the ulna at the posterior tip of the elbow. Since it is so near the surface it is frequently subject to trauma. Typically this is caused by constant irritation when the patient leans on the table whilst reading or writing but can also be caused by a fall on to a hard surface.[1]

Non-septic olecranon bursitis is a common condition. The exact incidence is unknown, as most cases are treated in the community. More information is available from hospital statistics about septic arthritis. One Canadian study based on 118 cases projected a minimum population annual incidence of 10/100,000. The mean age was 44 years and males predominated (88%).[2]

History

The principle symptoms are focal swelling overlying the posterior tip of the elbow, which may or may not be painless. Pain tends to lessen with the chronicity of the condition. The pain is often exacerbated by pressure, such as leaning on a table.

Clues about aetiology may be evident from the history. Onset may date from an isolated episode of trauma resulting in a contusion, or occupation or activity may cause recurrent microtrauma (eg carpet laying or writing at a table). Acute onset without trauma is suggestive of infection.

In the Canadian study of septic bursitis, 53% of cases had preceding injury. Symptoms in order of frequency were pain, redness, fever and chills.[2]

Examination[1]

A clearly demarcated swelling in the region of the posterior elbow tip is the classic finding. It has been described as having the appearance of a 'goose egg'. The area may be tender to palpitation, with redness and warmth, particularly if infection is present. Skin inspection may reveal contusion or abrasion if there was recent injury.

A difference in temperature of 2.2°C between the affected side and the normal side, measured by a surface temperature probe, is a significant pointer to infection.[3]

The range of movement of the joint is usually normal but may be limited at the end of flexion, due to pain. Unusual restriction of active or passive movement with a history of trauma raises the suspicion of fracture of the olecranon process.

Systemic symptoms are not usually present unless the infection is advanced, in which case there may be a fever.

Other joints should be examined for signs of crystal arthropathy or of systemic inflammatory processes such as rheumatoid arthritis (eg rheumatic nodules).

Elbow pain during active or passive movement may increase the clinician's suspicion of fracture of the olecranon process if there is a history of trauma.

The differential diagnoses can include fracture of the olecranon process, haemarthrosis,[4] inflammatory arthropathy,[5] crystal arthropathy,[6] autoimmune disease,[7] Ehlers-Danlos syndrome and synovial cyst. The most significant diagnostic decision is whether sepsis is present or absent.[1]

The diagnosis is usually made clinically but the following may be appropriate if an underlying disease process is suspected or in cases of diagnostic difficulty.

Laboratory studies

A raised white cell count will suggest infection. Check uric acid levels, rheumatoid factor, the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level.[1]

Imaging studies

If there is a history of significant trauma, a plain X-ray should be arranged to exclude fracture of the olecranon process.

Ultrasound may be helpful, particularly in the early stages. It may detect effusions, synovial proliferation, calcifications, loose bodies, rheumatoid nodules, gout tophi and septic processes.[8]

Rarely, MRI scanning may be needed to exclude osteomyelitis or abscess formation.[9]

Procedures

Aspiration of the bursa is useful, both for diagnostic purposes and to relieve symptoms. An 18-gauge needle should be used, and a zig-zag technique employed to minimise the risk of fistula formation.

If redness, fever, previous puncture wounds or cellulitis suggests infection, send the fluid for microscopy and culture.[10] Some studies state that a leukocyte count of 2,000-100,000 suggests inflammation, whilst a count above 100,000/mL suggests infection.[1] Gram staining, culture and sensitivity will help to identify any infective agent and to guide treatment.

The presence of crystals will suggest a crystal arthropathy. Monosodium urate crystals are characteristic of gout, calcium pyrophosphate or hydroxyapatite crystals are characteristic of pseudogout.[10]

Rheumatoid arthritis,[5] gout,[1] tuberculosis,[11] Mycobacterium szulgai infection,[12] HIV,[13] chronic kidney disease (may be due to uraemia or repeated microtrauma during dialysis),[14] plus any condition that compromises the immune system (eg alcohol, steroids,[15] diabetes[1]).

Physical therapy

There is a lack of a large evidence base, but structured exercises appear to be of benefit in non-septic bursitis.[7] The RICE method (= R est, I ce, C ompression, E levation) is also advocated.[1] Phonophoresis (the use of ultrasound to increase the absorption of topically applied drugs[16]) and electrical stimulation are also occasionally used to reduce pain and inflammation.[10]

Medical treatment

Septic bursitis should be treated with antibiotics, based on the results of microbiology tests. Most infections are due to Staphylococcus aureus,[2] although other organisms can occur.[17] If antibiotics have to be given empirically before the results of cultures are known, a penicillinase-resistant penicillin should be started, such as flucloxacillin.[18] A cephalosporin such as cefuroxime can be used in cases of penicillin allergy.[18] Antibiotics may be given orally, facilitating ambulatory treatment. However, if symptoms are particularly severe, the parenteral route may be required initially.[2]

Non-steroidal anti-inflammatory drugs can be of value in non-septic bursitis but may be less effective than injection with corticosteroid.[19]

Surgical procedures

Aspiration of the bursa followed by immediate instillation of corticosteroid may be used for the acute relief of inflammation. However installation of corticosteroids should be avoided if there is any suspicion of infection.[10] Patients should be counselled as to the complications, which can include swelling, infection and persistent drainage through the injection track. Ulnar nerve injury can occur if the median approach is used.[1] A compressive elbow sleeve may help prevent the re-accumulation of bursal fluid after aspiration.[1]

More interventional procedures are rarely needed. Drainage is occasionally required,[2] with removal of the bursa (bursectomy) being reserved for cases resistant to other treatment. Endoscopic removal of the bursa sac achieves good results.[20] Surgical treatment of aseptic olecranon bursitis gives long-lasting symptomatic relief to patients without rheumatoid arthritis. In cases of rheumatoid arthritis, similar procedures give long-term relief in only 40% of cases.[21]

Septicaemia and osteomyelitis can occur in severe septic bursitis, particularly if the condition presents late or the diagnosis is not immediately obvious.[22] Persistent pain and associated decreased functional use may be caused by the disease process in recalcitrant cases.[1]

Most patients respond well to treatment unless there is persistent infection.[1][22] Corticosteroid injection is usually effective in non-septic bursitis, and long-term sequelae are unusual.[23]

Patients should be advised to avoid excessive pressure over the elbow. Care should also be taken not to traumatise the elbow from persistent rubbing or contact sports. Elbow pads may help to prevent recurrence until the initial inflammation resolves.[1]

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Further reading & references

  1. Foye P et al; Physical Medicine and Rehabilitation for Olecranon Bursitis, eMedicine, Sep 2009
  2. Laupland KB, Davies HD; Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home Parenteral Therapy Program Study Group. Clin Invest Med. 2001 Aug;24(4):171-8.
  3. Smith DL, McAfee JH, Lucas LM, et al; Septic and nonseptic olecranon bursitis. Utility of the surface temperature probe in the early differentiation of septic and nonseptic cases.; Arch Intern Med. 1989 Jul;149(7):1581-5.
  4. Strickland RW, Vukelja SJ, Wohlgethan JR, et al; Hemorrhagic subcutaneous bursitis. J Rheumatol. 1991 Jan;18(1):112-4.
  5. Goldin DS, Stangler DA, Canoso JJ; Rheumatoid subcutaneous bursitis. J Rheumatol. 1981 Nov-Dec;8(6):974-8.
  6. Watrous BG, Ho G Jr; Elbow pain. Prim Care. 1988 Dec;15(4):725-35.
  7. Salzman KL, Lillegard WA, Butcher JD; Upper extremity bursitis. Am Fam Physician. 1997 Nov 1;56(7):1797-806, 1811-2.
  8. Blankstein A, Ganel A, Givon U, et al; Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. 2006 Dec;27(6):568-71. Epub 2006 Feb 22.
  9. Floemer F, Morrison WB, Bongartz G, et al; MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. 2004 Jul;183(1):29-34.
  10. Cardone DA, Tallia AF; Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. 2002 Dec 1;66(11):2097-100.
  11. Gottlieb J, Noer HH; Skeletal tuberculosis. Two case reports with a delay in diagnosis. Acta Orthop Belg. 1989;55(3):505-8.
  12. Maloney JM, Gregg CR, Stephens DS, et al; Infections caused by Mycobacterium szulgai in humans. Rev Infect Dis. 1987 Nov-Dec;9(6):1120-6.
  13. Buskila D, Tenenbaum J; Septic bursitis in human immunodeficiency virus infection. J Rheumatol. 1989 Oct;16(10):1374-6.
  14. Senecal L, Leblanc M; Olecranon bursitis in chronic haemodialysis patients. Nephrol Dial Transplant. 2001 Sep;16(9):1956-7.
  15. Roschmann RA, Bell CL; Septic bursitis in immunocompromised patients. Am J Med. 1987 Oct;83(4):661-5.
  16. Rosim GC, Barbieri CH, Lancas FM, et al; Diclofenac phonophoresis in human volunteers. Ultrasound Med Biol. 2005 Mar;31(3):337-43.
  17. Cea-Pereiro JC, Garcia-Meijide J, Mera-Varela A, et al; A comparison between septic bursitis caused by Staphylococcus aureus and those caused by other organisms.; Clin Rheumatol. 2001;20(1):10-4.
  18. McAfee JH, Smith DL; Olecranon and prepatellar bursitis. Diagnosis and treatment. West J Med. 1988 Nov;149(5):607-10.
  19. Smith DL, McAfee JH, Lucas LM, et al; Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med. 1989 Nov;149(11):2527-30.
  20. Ogilvie-Harris DJ, Gilbart M; Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy. 2000 Apr;16(3):249-53.
  21. Stewart NJ, Manzanares JB, Morrey BF; Surgical treatment of aseptic olecranon bursitis. J Shoulder Elbow Surg. 1997 Jan-Feb;6(1):49-54.
  22. Garcia-Porrua C, Gonzalez-Gay MA, Ibanez D, et al; The clinical spectrum of severe septic bursitis in northwestern Spain: a 10 year study. J Rheumatol. 1999 Mar;26(3):663-7.
  23. Stell IM; Management of acute bursitis: outcome study of a structured approach. J R Soc Med. 1999 Oct;92(10):516-21.
Original Author: Dr Laurence Knott Current Version:
Last Checked: 20/04/2011 Document ID: 968  Version: 22 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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