Olecranon Bursa Aspiration 

When a bursa becomes inflamed, it may be categorized as either septic or aseptic. Noninfective or aseptic bursitis is a sterile inflammation, which may occur secondary to acute trauma, overuse injury, crystal deposition (eg, gout, pseudogout), or systemic disease (eg, rheumatoid arthritis [RA], uremia, systemic lupus erythematosus).

Aseptic cases account for approximately two thirds of all bursitis diagnoses. Conversely, infective or septic bursitis is the inflammation of a bursa secondary to the seeding of the bursal sac with microorganisms; most commonly, these microorganisms are bacteria, but they can, rarely, be fungus or algae. Seeding most often occurs transcutaneously after trauma to the region overlying the bursa.^{[1, 2]}

Clinically, septic bursitis is difficult to distinguish from its aseptic counterpart. Roughly 40% of patents with septic bursitis are found to have clinically significant fever (>38°C/100.4°F). Bursal warmth is almost uniformly noted in infective cases but is observed only 50% of the time in those with no infection. Peribursal cellulitis is noted in more than 60% of septic bursitis cases but only 25% of noninfective cases. Tenderness is usually present in all bursitis cases; however, the degree of tenderness seems to be far more pronounced in septic bursitis than in aseptic bursitis.^[3]

Definitive diagnosis of septic bursitis can be made only by culture isolation of the causative organism. Bursal aspirates in septic cases almost always have elevated white blood cell counts (>100,000 WBC/µL) with a predominance of neutrophils. Fluid from inflamed aseptic bursa may show an increased WBC count; however, the predominant cell type is mononuclear. In addition, a bursal fluid glucose-to-serum glucose ratio < 50% is virtually exclusive to septic bursa.^{[4, 5]}

While olecranon bursitis is usually sterile, the olecranon bursa is the most frequent site of septic bursitis and, therefore, should not be injected with steroids before fluid analysis.^[6] See image below.

• Aspiration of inflamed olecranon bursa for fluid analysis

• Overlying cellulitis at the needle insertion site
• Bacteremia
• Joint prosthesis

• Inject a local anesthetic as described below in the Technique section.
• For more information, see Local Anesthetic Agents, Infiltrative Administration.

• Antiseptic solution
• Gauze pack, 4 X 4
• Sterile drapes
• Sterile gloves
• Lidocaine 1%
• Syringes, 10 mL (2)
• Needles, 18 gauge (2)
• Needle, 25 gauge
• Adhesive bandage

Position the patient sitting upright on a stretcher.

Rest the affected arm on a side table with the elbow flexed 90 º (see image below).

Identify the inflamed olecranon bursa and a needle insertion site over noninflamed skin. The insertion site should be posterolateral to avoid the ulnar nerve that is located medially (see image below).

Ask the patient to lift his or her elbow off the side table.

Apply an antiseptic solution using circular movement from the olecranon and away.

Place a sterile drape on the side table and ask the patient to lower his or her elbow back on the sterile drape.

Apply sterile drapes around the prepared skin (see image below).

Arm a sterile syringe filled with 1 mL of lidocaine 1% with a 25-ga needle and use it to raise a skin wheal over the needle insertion site (see image below).

Arm a new 10-mL syringe with an 18-ga needle and break the vacuum.

Insert the needle through the raised skin wheal and advance it into the most dependent aspect of the bursa.

Aspirate the bursa to drain it completely by simultaneously pulling on the syringe with one hand and milking the bursa with the other (see image below).

Withdraw the needle (see image below).

Clean the skin and place an adhesive bandage over the injection site.

• Do not insert the needle on an area of overlying cellulitis as this may result in infection of the bursa or joint.
• To better seal the needle tract, use the Z-tract technique by pulling the skin overlying the needle insertion side either medially or laterally.

• Local infection is a rare complication that can be minimized by choosing a needle insertion site over noninflamed skin.
• Fistula formation is a possible complication, given the short subcutaneous distance between skin entry and bursa. Some authors recommend using the Z-tract technique to minimize the risk of fistula formation.

• To aspirate an inflamed olecranon bursa with the Z-track technique, first follow the preparatory steps above, including positioning, sterile preparation, anesthesia, and landmark identification.
• Before inserting the needle, pull the skin overlying the needle insertion side either medially or laterally. This creates a longer subcutaneous needle tract and better seals the tract once the needle is removed.
• After needle insertion, complete the aspiration procedure as described above in the Technique section.