Download Olecranon Bursitis

Musculoskeletal
Medicine for
Medical
Students
Olecranon bursitis
Author: Joseph Bernstein Version: 8
Date: 06-Apr2014 11:37
Table of Contents
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1
Description 3
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2
Structure and function 4
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3
Patient presentation 5
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4
Clinical Evidence 6
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5
Epidemiology 7
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6
Differential diagnosis 8
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7
Red flags 9
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8
Treatment options and outcomes 10
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9
Risk factors and prevention 11
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10
Miscellany 12
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11
Key Terms 13
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12
Skills 14
1 Description
Olecranon bursitis is a condition in which the soft tissue overlying
the olecranon at the elbow is inflamed. Inflammation of the
olecranon bursa can be the result of direct trauma, repetitive use,
or inflammatory conditions such as gout or rheumatoid arthritis.
Occasionally, the fluid in the olecranon bursae can become
infected – a condition that requires surgical drainage. Often,
however, the olecranon bursitis runs an innocent course.
CLINICAL PHOTO of Olecranon bursitis
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2 Structure and
function
The body places bursae (the plural of "bursa") in those areas
where the normal structures must glide (e.g. the skin overlying
the olecranon) to facilitate that gliding by reducing friction.
The word “bursa” literally means “sack”, however, it is best to
think of these “sacks” as plastic bags (similar to those used to
hold trash or groceries, say), in their compressed, unused state.
That is, a healthy bursa is like a plastic bag before it is filled:
namely, a structure with two layers of material, closely opposed;
layers that glide smoothly against each other. Only when they
are filled (with bursal fluid or groceries in bursae and plastic bags
respectively) do they become “sack-like”. That is, whereas the
inner surfaces of bursae can become filled with fluid (and hence
earning their container-connoting name), in the natural state they
are empty. If the bursa is filled with fluid, but is not inflamed or
infected, sometimes the fluid can be resorbed over time.
However, if it does not resorb itself, the fluid can become
infected.
Bursitis is the clinical entity in which the bursa becomes inflamed
and fluid-filled. This inflammation can be caused by direct trauma,
repetitive use, prolonged pressure and systemic inflammatory
conditions (such as gout or rheumatoid arthritis). Bursitis can be
caused by infection directly, e.g. insect bite or puncture wound.
At times, fluid collecting for other reasons can become
secondarily infected.
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3 Patient
presentation
The hallmark of olecranon bursitis is a mass at the elbow over
the olecranon.
Tenderness, redness and warmth are classic signs, but may be
absent. At times the mass is not at all painful, unless pressure is
applied.
Olecranon bursitis can be caused by conditions such as
rheumatoid arthritis or gout, and therefore the presentation may
be colored by co-existing symptoms of those conditions (for
example, arthrosis within the elbow itself).
Patients on dialysis seem to be at particular risk for olecranon
bursitis (for reasons that are not entirely clear).
At times there is a history of direct trauma to the elbow;
sometimes there is a history of repetitive use; and at other times
there is no antecedent history at all.
Even in cases where the bursa is not painful, hyper flexing the
elbow can produce pain, as this motion tends to increase the
pressure within the bursa. Along those lines, bursitis may impede
full range of motion.
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4 Clinical Evidence
Fluid from olecranon bursitis can be drained and sent for culture.
Culture is the definitive test; gram staining may be negative in
many cases that ultimately turn out to be infectious.
X-rays may show an olecranon spur. There may be calcification
within the bursa itself. An MRI can demonstrate the fluid
collection but is rarely indicated.
MRI of Olecranon bursitis
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5 Epidemiology
The precise prevalence of olecranon bursitis is not known. It is a
common condition, and therefore high (if not first) on the
differential diagnosis list of painless masses on the elbow.
Approximately 20-25% of cases of known septic bursitis turn out
to be infectious. Approximately 5-10% of patients on dialysis may
have this condition.
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6 Differential
diagnosis
There are two levels of diagnostic thinking required: first, “is this
mass bursitis?” And second, “if this is bursitis, what has caused
it?” (Along those lines, the question “is this bursa infected or
prone to be?” should be kept to the forefront.)
A mass overlying the elbow in the setting of normal radiographs
(or radiographs showing only calcification within the bursa) can
be considered bursitis until proven otherwise.
The causes of bursitis usually can be deduced from the history.
As noted, increased redness, warmth, and tenderness
(especially in a patient with an imperfect immune system) should
prompt an infection work-up.
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7 Red flags
Bursal fluid can serve as a culture medium and easily become
infected. Approximately 25% of cases of olecranon bursitis will
turn out to be infectious. Septic bursitis is heralded by more
redness and warmth, and is much more likely to be painful.
Patients on dialysis should be suspected of having septic bursitis.
Septic bursitis can be diagnosed definitively with an aspiration
and culture. A cell count of the aspirate can be a useful clinical
guide for initiating empiric treatment.
CLINICAL PHOTO showing aspiration of olecranon bursitis
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8 Treatment options
and
outcomes
The first line treatment of aseptic bursitis includes rest,
compression (with ace wrap), ice and NSAIDs.
Also, ensuring that any underlying process that may be
responsible (e.g. gout) is well controlled is a wise step.
Minimizing the gliding across the bursa may help control the
bursitis, but in general the elbow is apt to get stiff when
immobilized; as such, prolonged immobilization should be
avoided. Typically, immobilization with ace wrap will provide
enough compression but will not immobilize the elbow
completely.
If the first line treatment is not successful, needle aspiration (with
the addition of a steroid) can be helpful. Aspiration can be
diagnostic as well as therapeutic.
If sepsis is considered, aspiration should be performed and
antibiotics started. If the infection does not clear after the first
aspiration and antibiotics, surgical drainage may be needed.
Treatment of bursitis tends to be effective, yet recurrence is
common. That is often the case because the inciting cause
remains present, e.g. a worker continues to put pressure on the
elbow, or the gout flares again. In general, however, long-term
impairment is rare.
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9 Risk factors and
prevention
People whose occupations require resting on the elbows – for
example carpet installation or gardening – are best served with
elbow pads.
Dialysis and immune compromise in general are risk factors for
infectious bursitis that cannot be prevented per se. Vigilance to
make sure that infections are detected early is best.
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10 Miscellany
The "bible" remedy used for ganglion cysts (smashing the mass
with a heavy book) is a poor choice for olecranon bursits. If
nothing else, a heavy blow may damage the skin and increase
the chance of infection.
The word bursa is similar to the word “bursar”, the official at a
university who collects the tuition – and carries it away in money
sacks. The simple English word “purse” has a similar root.
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11 Key Terms
Bursa; bursitis; aspiration
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12 Skills
Recognize bursitis and associated “red flags”; aspirate bursa
under sterile conditions
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