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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.
Non-septic olecranon bursitis is a common condition. The exact incidence is unknown, as most cases are treated in the community. It typically occurs in men between the ages of 30-60. 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%).
The principal 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.
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 palpation, 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.
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, rheumatoid arthritis and other inflammatory arthropathies, gout and pseudogout, systemic lupus erythematosus and other autoimmune diseases, Ehlers-Danlos syndrome, Baker's cyst and septic arthritis. The most significant diagnostic decision is whether sepsis is present or absent.
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.
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.
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. MRI scanning may be contributory.
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 suggest infection, send the fluid for microscopy and culture. 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.
- Rheumatoid arthritis.
- Chronic kidney disease (may be due to uraemia or repeated microtrauma during dialysis).
- Any condition that compromises the immune system.
The RICE method (= Rest, Ice, Compression, Elevation) is advocated. Phonophoresis (the use of ultrasound to increase the absorption of topically applied drugs) is also occasionally used to reduce pain and inflammation.
Septic bursitis should be treated with antibiotics, based on the results of microbiology tests. Most infections are due to Staphylococcus aureus, although other organisms can occur. If antibiotics have to be given empirically before the results of cultures are known, a penicillinase-resistant penicillin should be started, such as flucloxacillin. A macrolide such as erythromycin can be used in cases of penicillin allergy. Antibiotics may be given orally, facilitating ambulatory treatment. However, if symptoms are particularly severe, the parenteral route may be required initially.
A Cochrane review has found limited evidence for the effectiveness of methylprednisolone injection combined with naproxen.
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. A Cochrane review has found limited evidence for the effectiveness of methylprednisolone injection combined with naproxen. 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. A compressive elbow sleeve may help prevent the re-accumulation of bursal fluid after aspiration.
More interventional procedures are rarely needed. Drainage is occasionally required with removal of the bursa (bursectomy) being reserved for cases resistant to other treatment. Endoscopic removal of the bursa sac achieves good results. An extrabursal endoscopic technique has been observed which avoids the complications often observed with olecranon wounds. 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.
Septicaemia and osteomyelitis can occur in severe septic bursitis, particularly if the condition presents late or the diagnosis is not immediately obvious. Persistent pain and associated decreased functional use may be caused by the disease process in recalcitrant cases.
Most patients respond well to treatment unless there is persistent infection. Corticosteroid injection is usually effective in non-septic bursitis and long-term sequelae are unusual.
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.
Further reading & references
- Villasenor-Ovies P, Vargas A, Chiapas-Gasca K, et al; Clinical anatomy of the elbow and shoulder. Reumatol Clin. 2012 Dec-2013 Jan;8 Suppl 2:13-24. doi: 10.1016/j.reuma.2012.10.009. Epub 2012 Dec 7.
- Lockman L; Treating nonseptic olecranon bursitis: a 3-step technique. Can Fam Physician. 2010 Nov;56(11):1157.
- 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.
- Brown D et al; Elbow Disorders, 2004
- Elliott J; Olecranon Bursitis, Sport and Soft Tissue Disorders, 2012
- Olecranon bursitis; NICE CKS, October 2010
- Approach to Articular and Musculoskeletal Disorders, Harrison's Internal Medicine, 2011
- Radunovic G, Vlad V, Micu MC, et al; Ultrasound assessment of the elbow. Med Ultrason. 2012 Jun;14(2):141-6.
- Wenzke DR; MR imaging of the elbow in the injured athlete. Radiol Clin North Am. 2013 Mar;51(2):195-213. doi: 10.1016/j.rcl.2012.09.013. Epub 2013 Jan 12.
- Cardone DA, Tallia AF; Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. 2002 Dec 1;66(11):2097-100.
- Maldonado I, Eid H, Rodriguez GR, et al; Rheumatoid nodulosis: is it a different subset of rheumatoid arthritis? J Clin Rheumatol. 2003 Oct;9(5):296-305.
- Rakieh C, Conaghan PG; Diagnosis and treatment of gout in primary care. Practitioner. 2011 Dec;255(1746):17-20, 2-3.
- Barham GS, Hargreaves DG; Mycobacterium kansasii olecranon bursitis. J Med Microbiol. 2006 Dec;55(Pt 12):1745-6.
- Perez C, Huttner A, Assal M, et al; Infectious olecranon and patellar bursitis: short-course adjuvant antibiotic therapy is not a risk factor for recurrence in adult hospitalized patients. J Antimicrob Chemother. 2010 May;65(5):1008-14. doi: 10.1093/jac/dkq043. Epub 2010 Mar 1.
- Chao CT, Wu MS; Dialysis elbow. QJM. 2012 May;105(5):485-6. doi: 10.1093/qjmed/hcr054. Epub 2011 Mar 30.
- Crowther M; Elbow pain in pediatrics. Curr Rev Musculoskelet Med. 2009 Jun;2(2):83-7. doi: 10.1007/s12178-009-9049-4. Epub 2009 Mar 14.
- Saliba S, Mistry DJ, Perrin DH, et al; Phonophoresis and the absorption of dexamethasone in the presence of an occlusive dressing. J Athl Train. 2007 Jul-Sep;42(3):349-54.
- Wasserman AR, Melville LD, Birkhahn RH; Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. 2009 Oct;37(3):269-72. Epub 2007 Jul 20.
- Leitner E, Valentin T, Hoenigl M, et al; First report of Nocardia asiatica olecranon bursitis in an immunocompetent traveler returning to Austria. J Clin Microbiol. 2013 Jul;51(7):2461-2. doi: 10.1128/JCM.00517-13. Epub 2013 May 1.
- Skedros JG, Keenan KE, Trachtenberg JD; Candida glabrata olecranon bursitis treated with bursectomy and intravenous caspofungin. J Surg Orthop Adv. 2013 Summer;22(2):179-82.
- Rinkel WD, Schreuders TA, Koes BW, et al; Current Evidence for Effectiveness of Interventions for Cubital Tunnel Syndrome, Radial Tunnel Syndrome, Instability, or Bursitis of the Elbow: A Systematic Review. Clin J Pain. 2013 Mar 24.
- Brinks A, Koes BW, Volkers AC, et al; Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord. 2010 Sep 13;11:206. doi: 10.1186/1471-2474-11-206.
- Masala S, Fiori R, Bartolucci DA, et al; Diagnostic and therapeutic joint injections. Semin Intervent Radiol. 2010 Jun;27(2):160-71. doi: 10.1055/s-0030-1253514.
- Anderson B; Office Orthopedics for Primary Care: Treatment, 2006.
- Ogilvie-Harris DJ, Gilbart M; Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy. 2000 Apr;16(3):249-53.
- Tu CG, McGuire DT, Morse LP, et al; Olecranon extrabursal endoscopic bursectomy. Tech Hand Up Extrem Surg. 2013 Sep;17(3):173-5. doi: 10.1097/BTH.0b013e31829c0535.
- Stewart NJ, Manzanares JB, Morrey BF; Surgical treatment of aseptic olecranon bursitis. J Shoulder Elbow Surg. 1997 Jan-Feb;6(1):49-54.
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|Original Author: Dr Laurence Knott||Current Version: Dr Laurence Knott||Peer Reviewer: Dr John Cox|
|Last Checked: 18/10/2013||Document ID: 968 Version: 23||© EMIS|