Olecranon Bursitis

Other Names

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

Causes

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

Pathoanatomy

• Bursae are fluid-filled sacks that minimize friction and facilitate the gliding of overlapping structures
• The olecranon bursa represents a superficial bursa located between the deep surface of the Triceps Brachii anatomy and the bony Olecranon
• Overall, 33-74% of patients have risk factors
• General
  • Trauma
• Systemic Disease
  • Diabetes Mellitus
  • Chronic Kidney Disease
  • Gout
  • Pseudogout
  • Rheumatoid Arthritis
  • HIV
  • Psoriasis
• Risk factors for septic bursitis^[11]
  • Impaired immunity
  • Chronic steroid use
  • Malignancy
  • Alcohol Abuse

Differential Diagnosis

• Fractures
  • Adult
    • Radial Head Fracture
    • Olecranon Fracture
    • Capitellum Fracture
    • Coronoid Fracture
    • Terrible Triad of Elbow
  • Pediatric
    • Nursemaids Elbow
    • Supracondylar Fracture
    • Lateral Condyle Fracture (Peds)
    • Medial Condyle Fracture (Peds)
    • Olecranon Fracture (Peds)
    • Radial Head Fracture (Peds)
    • Medial Epicondyle Fracture (Peds)
    • Salter Harris Fracture
• Dislocations & Instability
  • Elbow Dislocation
  • Proximal Radioulnar Joint Instability
• Tendinopathies
  • Lateral Epicondylitis
  • Medial Epicondylitis
  • Distal Biceps Tendon Injury
  • Triceps Tendon Injury
• Bursopathies
  • Olecranon Bursitis
• Ligament Injuries
  • Lateral Collateral Ligament Injury (Elbow)
  • Ulnar Collateral Ligament Injury
• Neuropathies
  • Cubital Tunnel Syndrome
  • Radial Tunnel Syndrome
• Arthropathies
  • Elbow Arthritis
• Other
  • Valgus Extension Overload
  • Posteromedial Rotatory Instability
  • Posterolateral Rotatory Instability
  • Osteochondral Defect
• Pediatric Considerations
  • Little League Elbow
  • Panners Disease (Avascular Necrosis of the Capitellum)
  • Nursemaids Elbow (Radial Head Subluxation)

Diagnosis

• 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^[12]
  • 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
• Difficult to differentiate nonseptic olecranon bursitis from septic olecranon bursitis

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 joint effusion, including a posterior fat pad sign
  • This can be sterile or infectious
• Olecranon spurs are associated with olecranon bursitis

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
  • The gold standard for diagnosing septic arthritis is a positive culture of bursal fluid, however not helpful in deciding to initiate treatment^[15]
  • Send fluid for gram stain, culture, cell count, crystal analysis, glucose, protein
• Findings
  • Gram stain is unreliable, only positive between 50-100% of the time in culture-positive cases
  • 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
  • Bursal glucose <50% of serum glucose favors septic bursitis, however not reliable
  • Comparing skin temperature with a difference of 2.2°C between the affected limb and unaffected limb is 100% sensitive, 94% specific^[19]
  • 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^[20]

Treatment

Prevention

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

Nonoperative

• Management is based on the etiology of the bursitis
• Noninfectious or aseptic
  • Activity modification
  • Elbow Compression Sleeve, preferably with padding
  • NSAIDS
  • Typically managed conservatively
  • Corticosteroid injection increases the risk of septic bursitis and the formation of the sinus tract
    • 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 the 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
  • Antibiotics that cover Staph Aureus and beta-hemolytic strep
  • The average length of treatment is 10-14 days, less may be insufficient
  • 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^[25]
• Septic Bursitis
  • No clear advantage to surgical management over aspiration or incision and drainage
  • Indications^[26]
    • 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