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Olecranon Bursitis

Olecranon bursitis is a common condition characterized by pain, swelling and inflammation of the olecranon bursa. One third of episodes are septic.


Presentation

Painless swelling is the most common manifestation in non-inflammatory, aseptic form of olecranon bursitis. Most of the patients have difficulty in flexing the elbow beyond 90 degrees. They may also complain of difficulty in resting the elbow. Those with septic and crystal-induced olecranon bursitis may complain of moderate to severe pain in the region. Fever and malaise are also common.

Patients may often notice swelling at the posterior part of the elbow. It is often associated with pain which may increase with pressure. Thus, a patient leaning on elbow or rubbing it against the table or other structures may have increased pain. Swelling of the bursa may have chronic or acute onset. The elbow may protrude further than normal and this increases the risk of injury due to bumping. Sudden onset of swelling is often noted in infection or repeated trauma. If chronic irritation is the cause, onset of swelling may be gradual.

The swelling is fluctuant and is clearly demarcated over the olecranon process. It often appears as an egg-like structure. The posterior elbow may appear warm and red, and be tender on palpation. Severe pain is noticed in case of infections. If the trauma is recent, abrasions or contusions can be noticed on the skin. Those with other systemic inflammatory diseases like rheumatoid arthritis may have inflammation in other sites also. Patients with rheumatoid arthritis may have rheumatoid nodules at the elbow. If bursitis is associated with cellulitis, the inflammation may extend distally. 

Amyloidosis
  • Aetiologies of articular manifestations are numerous, including secondary hyperparathyroidism, crystal arthropathy such as gout and hydroxyapatite deposition, amyloidosis, aluminum overload and infectious processes [ 1 ].[academic.oup.com]
Night Sweats
  • A 25-year-old male patient was admitted with fever of 20-day duration, right-sided hip pain, and night sweating. A Brucella standard tube agglutination test was positive at a titer of 1/160.[ncbi.nlm.nih.gov]
Elbow Pain
Neglect
  • Thirdly, isolation of C parapsilosis was neglected at the start so that antifungal treatment was delayed, leading to the need for surgery.[ard.bmj.com]

Workup

Physical examination is the most common confirmatory diagnostic test for the aseptic, non-inflammatory form of olecranon bursitis. This may not require any further specific tests for diagnosis. In about one-third of the cases, radiographs may show an olecranon spur. Laboratory studies are recommended only if there are any other underlying conditions. This includes a complete blood count and a differential blood count to check for infection that result in bursitis. If gout is suspected, uric acid level is measured. Rheumatoid arthritis is tested using erythrocyte sedimentation rate and C-reactive protein level.

Differential count helps to determine whether bursitis is caused by infection or mere inflammation. Culture of bursal fluid aids in identifying the causative organism and to test whether the bacteria is sensitive for a particular antibiotics. This is important in deciding the treatment plan as the antibiotic has to be changed in case of antibiotic resistance. Cloudy fluid in the aspirate recommends Gram stain, leukocyte count, culture and antibiotic resistance testing. This is particularly important if there is no history of cumulative or other forms of trauma to the region. Presence of blood in the aspirate from the bursa suggests hemorrhagic bursitis. Aspirate also helps to check for monosodium urate crystals in gout or calcium pyrophosphate crystals in pseudogout [7].

If there was significant trauma to the site, radiography is recommended. This will help to assess any fracture to olecranon and also to check for the presence of osteophyte at the point of insertion of triceps. Indications of bursitis like effusions, synovial proliferation, loose bodies, and inflammation, can be diagnosed with the help of ultrasonography [8]. Magnetic resonance imaging is not used unless to rule out the possibility of certain conditions like stress fracture, triceps tendionopathy, or osteomyelitis [9]. Differential diagnosis include rheumatoid nodule, lipoma, tophus, elbow synovitis, and olecranon spur.

Mycobacterium Kansasii
  • A case is reported of a post-traumatic olecranon bursitis caused by Mycobacterium kansasii following an injury sustained in a public swimming pool.[ncbi.nlm.nih.gov]
  • We present a case of Mycobacterium kansasii olecranon bursitis in a woman with known immunosuppression secondary to the treatment received for her Behçet's disease.[ncbi.nlm.nih.gov]

Treatment

The first step in the treatment of this condition is the prevention of further injury to the elbow involved. An elastic pad will provide protection and adequate compression to the bursa. Care should be taken to protect the affected part during work. Non-steroidal anti-inflammatory drugs (NSAIDs) are suggested for traumatic, non-inflammatory bursitis [10]. If the bursa is large due to swelling, aspiration should be carried out. The elbow should be then applied with a compressive wrap and splint for a few days.

Aspiration is performed for septic bursitis as well, and if cellulitis is present in the tip, empirical antibiotic treatment is suggested. Route of administration of antibiotics depends on factors like appearance of elbow, presence of systemic illness, and also general health of the patient. If there is extensive infection, systemic disease or immunosuppression, intravenous cephalosporin is recommended. Once there is considerable improvement in the symptoms, it can be converted to oral form. Surgery may be needed if bursitis does not improve with the standard management strategies. Corticosteroid injections to the bursa are helpful in case of traumatic and crystal-induced olecranon bursitis.

Surgery is recommended in case of chronic bursal fluid drainage. It can be performed through open or arthroscopic methods and is used in both traumatic and septic bursitis. Suction drains are used for few days after the surgical procedure. Recurrence can be prevented by splinting the elbow at 60 degrees or more for two weeks.

Prognosis

In general, olecranon bursitis responds well to joint aspirations and some additional treatment. This is particularly true if no infections are present. Recurrence is noted in some cases of olecranon bursitis and in such cases even a minor bump may result in considerable effusion in the elbow. Persistent pain may result from some of the complications of the condition. It may also lead to reduced functionality of the upper extremity. Bursal aspiration may result in complications like bleeding, bruising, allergy, swelling, infection, cardiac arrhythmia and peripheral nerve dysfunction.

Etiology

The bursa plays an important role in reducing friction between skin and olecranon process during the movement of the elbow. Trauma, mostly repetitive, is one of the most common causes of bursitis. Occasionally, a single, direct blow to the region may also result in traumatic bursitis. Many acute injuries to the elbow during sports activities cause inflammation of bursa. Thus football players, particularly those who play in artificial turf, are at an increased risk of developing this condition. One of the most common causes of this condition is cumulative minor trauma from direct pressure on the posterior elbow [2]. Mechanics, miners, gardeners, plumbers, students, gymnasts, students and draftsmen have a high risk of developing bursitis.

Infection of bursa is another, but less common cause of olecranon bursitis. Diseases affecting the bursa, including rheumatoid arthritis, gout and chondrocalcinosis, result in inflammation. Laceration at the affected site and bacteremia also result in bursal infection. Many hemodialysis patients also develop inflammation of bursa. Systemic conditions like uremia, diabetes mellitus, alcoholism, intravenous drug use, and steroid therapy are presumed to be risk factors of olecranon bursitis. In many cases no identifiable causes are present and cumulative minor irritation of the bursa is presumed to be the cause of the condition.

Epidemiology

Olecranon bursitis is a relatively common condition in general population. It frequently affects men in the age group of 30-60 years. Based on hospital records, it is estimated that this form of bursitis occurs in 0.1-1.2 per 100,000 visits to the emergency department [3]. Prevalence of this condition as per hospital records in other studies varies from 20 to 80% [4]. About 20% of olecranon bursitis is caused by septic bursitis [5]. Gout and chondrocalcinosis also result in a small proportion of bursitis. In about 25% of the cases, the actual cause of inflammation is not known. History of recent trauma or sustained pressure on the elbow increases the risk of bursa inflammation.

Sex distribution
Age distribution

Pathophysiology

Cumulative trauma to the posterior elbow is one of the most common causes of this condition. Trauma increases the vascularity in the region, stimulating the production of bursal fluid. This favors the formation of a fibrin coating on the wall of the bursa. Repeated, prolonged positioning of the elbow leads to anticoagulation, another contributing factor of olecranon bursitis. About 20% of olecranon bursitis is caused by septic bursitis. Most of these have breaks in the skin and the most common source of septic bursitis is transcutaneous. In such cases, bursal fluid may contain Staphylococcus aureus [6].

Prevention

Wearing well-fitted elbow pads while participating in activities that increase the risk of trauma to the olecranon is very effective in preventing this condition. If the cause of the disease is minor, repeated trauma, change of habits which does not apply pressure on the region would be helpful.

Summary

Olecranon bursitis, also known as miner’s elbow or draftsman’s elbow, is a common condition characterized by the inflammation of synovium-lined sac overlying olecranon process [1]. The bursa is an effective cushion for the tip of the olecranon, and reduces the friction during the movement of the elbow. As it is superficially placed between the ulna and the skin without the protection of soft tissues, it is vulnerable to injuries. Olecranon bursitis may also be caused by infections or repetitive stress to the elbow. In many cases, no identifiable cause is found. It is categorized into acute or chronic forms. Acute bursitis is characterized by cystic swelling over the posterior olecranon process, while chronic bursitis is characterized by palpable thickening on the walls of the bursa.

Patient Information

Bursitis refers to the inflammation of the bursa, the small sac of fluid in the joints that help in smooth movement. Olecranon bursitis affects the olecranon bursa at the back of the elbow. Olecranon bursitis may be caused by any of the three reasons – inflammation, injury or infection. Inflammation due to pressure on the bursa is the most common cause of olecranon bursitis. Injury may be due to a sudden blow or recurrent trauma to the bursa due to various activities. Football players, particularly those who play in the artificial turf, are considered to be at an increased risk of developing bursitis. There are many other occupations and activities which increase the chance of developing this condition. This includes gardening, mining, draftsmanship, and gymnastics. Infection may be caused by an injury at the site of bursa or on a tissue near bursa. In some very rare cases, blood-borne infection may also result in olecranon bursitis.

Pain, particularly during movement of the elbow is the most common symptom of this condition. It may also be manifested in the form of a swelling at the posterior region of the involved elbow. The swelling may be tender and often moves when touched. Swelling of the elbow is caused by the accumulation of fluid in the region. In the presence of infection, the swelling may be reddish and warm to touch. Fever and malaise is also common in case of bursitis caused by infection.

This condition is often diagnosed with physical examination and medical history of the patient. If trauma is the cause of the condition, radiography may be suggested to rule out the chances of olecranon fracture. If infection of bursa is suspected, the fluid from the region may be drained for culture. This helps to identify the organism and to decide on the treatment modality for controlling the same.

Avoiding further trauma to the region is the first step in the treatment of olecranon bursitis. Well-fitting elbow pad is helpful in providing adequate protection and also to prevent further injury to the elbow. Acute form of bursitis is treated by draining the fluid from the bursa and by injecting corticosteroids to reduce inflammation. Antibiotics are recommended for bursitis caused by infections. Surgery is suggested if no improvement is seen in the symptoms even after the standard management modalities.

References

Article

  1. Snider RK. Olecranon bursitis. In: Snider RK, ed. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:156-9.
  2. Canoso JJ. Idiopathic or traumatic olecranon bursitis. Clinical features and bursal fluid analysis. Arthritis Rheum. 1977;20:1213-1216. 
  3. Mathieu S, Prati C, Bossert M, et al. Acute prepatellar and olecranon bursitis. Retrospective observational study in 46 patients. Joint bone spine. 2011;78:423-424. 
  4. Ho G, Tice AD, Kalpan SR. Septic bursitis in the prepatellar and olecranon bursae: an analysis of 25 cases. Ann Intern Med 1978; 89: 21-27. 
  5. Jaffe L, Fetto JF. Olecranon bursitis. Contemp Orthop. 1984;8:51-56. 
  6. Zimmermann III B, Mikolich DJ, Ho Jr. G. Septic bursitis. Semin Arthritis Rheum. 1995;24:391-410. 
  7. Schumacher HR. Arthrocentesis, synovial fluid analysis, and synovial biopsy. In: Schumacher HR, ed.Primer on Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation; 1993:67-72.
  8. Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. Dec 2006;27(6):568-71.
  9. Floemer F, Morrison WB, Bongartz G, Ledermann HP. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. Jul 2004;183(1):29-34.
  10. Smith DL, McAfee JH, Lucas LM, et al. Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med. 1989;149:2527-2530. 

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Last updated: 2018-06-22 05:22