Olecranon Bursitis

Olecranon bursitis is a condition characterized by swelling, redness, and pain at the tip of the elbow. If the underlying cause is due to an infection, fever may be present. The condition is relatively common and is one of the most frequent types of bursitis. Olecranon bursitis caused by an injury will usually go away on its own. The body will absorb the blood in the bursa over several weeks, and the bursa should return to normal. If swelling in the bursa is causing a slow recovery, a doctor may insert a needle to drain the blood and speed up the process. If a septic bursitis is left untreated, the fluid inside the bursa can turn to pus. In addition, the infection can spread to the bloodstream and other parts of the body. If the infection spreads, symptoms will become worse and the infection can even become life-threatening.

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
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 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