eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Olecranon Bursitis: Differential Diagnoses & Workup
Updated: Sep 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Crystalline inflammatory arthropathy (eg, gout, pseudogout)
Fracture of the olecranon process of the ulna
Synovial cyst of the elbow joint
Perhaps the most important consideration is whether or not an infection is present.
Workup
Laboratory Studies
- Usually, laboratory studies are necessary only if the clinician suspects that an underlying condition is present. It is necessary to check for infection (complete blood count [CBC], including a differential count of the white blood cells [WBCs]). Tests should also be run for rheumatoid factor, the erythrocyte sedimentation rate, and the C-reactive protein level, in order to assess for rheumatoid arthritis. The uric acid level should be checked in order to assess for gout.
- If infection is suggested due to fever, redness, previous puncture wounds, or cellulitis, the bursa should be aspirated and the fluid should be sent for immediate Gram stain for bacteria, as well as a cell count (WBCs, red blood cells [RBCs]).
- The leukocyte count can help to determine whether the fluid is infectious or merely inflammatory.
- Within synovial aspirates, WBC counts are assessed as follows:
- A WBC count less than 200/µL is considered normal.
- A WBC count is considered noninflammatory at 200-2000/µL.
- A WBC count in the range of 2000-100,000/µL is considered to be an indication of inflammation.
- A WBC count greater than 100,000/µL is considered to be an indication of a septic condition.
- Gram stain also is helpful to determine quickly whether bacterial infection appears to be present.
- If the Gram stain is positive, antibiotics should be started immediately and bursal corticosteroid injection should be avoided.
- Even if the Gram stain is negative or initially unavailable, antibiotics may seem indicated based on the mechanism of injury (eg, abrasion or puncture), physical examination findings suggestive of infection (eg, fever, significant local redness and warmth), or the gross appearance of the aspirate (eg, turbid, purulent).
- Gram stain can be followed by culture and sensitivity testing. The culture and sensitivity results should guide the use of antibiotics in cases of bacterial infection.
- Crystal analysis may reveal monosodium urate crystals in a patient with gout, calcium pyrophosphate crystals in a patient with pseudogout, or hydroxyapatite crystals.
Imaging Studies
- If there has been significant trauma, a radiograph of the elbow should be obtained to assess for possible fracture.
- The use of ultrasonography has been shown to be extremely effective in the diagnosis of olecranon bursitis and other soft-tissue lesions in the olecranon areas by rapidly demonstrating effusions, synovial proliferation, loose bodies, increased blood flow consistent with inflammation, tendonitis with calcifications, and other indications of bursitis.9
- In rare cases, magnetic resonance imaging (MRI) may be indicated to exclude concomitant osteomyelitis or abscess formation.10,11
Procedures
- Bursal aspiration still remains the criterion standard to differentiate septic and aseptic olecranon bursitis.2,3,4 (See images below and Images 5-7.)
- The olecranon bursa can be aspirated using an 18-gauge needle inserted through the posterior-lateral approach, using a zigzag approach to minimize the risk of fistula formation.
- Aspiration can be helpful diagnostically because any cloudy fluid should be sent for immediate Gram stain, leukocyte count, and culture, with tests for antibiotic sensitivity.
- Aspiration can also be therapeutic, because it relieves the swelling.
- If the clinician is confident that no infection is present, corticosteroid injection can be considered (for instance, immediately after aspiration of the fluid).12
Needle aspiration of olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Olecranon bursitis aspiration of a hemorrhagic effusion. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
After fluid is removed from the olecranon bursa, an elastic tubular compressive sleeve can be used to minimize repeat accumulation of the fluid. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Histologic Findings
In cases of bacterial infection, synovial fluid analysis may reveal increased WBC counts.13
More on Olecranon Bursitis |
| Overview: Olecranon Bursitis |
 Differential Diagnoses & Workup: Olecranon Bursitis |
| Treatment & Medication: Olecranon Bursitis |
| Follow-up: Olecranon Bursitis |
| Multimedia: Olecranon Bursitis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. Jul 20 2007;[Medline].
Lass-Flörl C, Mayr A. Human protothecosis. Clin Microbiol Rev. Apr 2007;20(2):230-42. [Medline]. [Full Text].
Wagner C, Iking-Konert C, Hug F, et al. Cellular inflammatory response to persistent localized Staphylococcus aureus infection: phenotypical and functional characterization of polymorphonuclear neutrophils (PMN). Clin Exp Immunol. Jan 2006;143(1):70-7. [Medline]. [Full Text].
Senécal L, Leblanc M. Olecranon bursitis in chronic haemodialysis patients. Nephrol Dial Transplant. Sep 2001;16(9):1956-7. [Medline]. [Full Text].
Wessolossky M, Haran JP, Bagchi K. Paecilomyces lilacinus olecranon bursitis in an immunocompromised host: case report and review. Diagn Microbiol Infect Dis. Jul 2008;61(3):354-7. [Medline].
Turan H, Serefhanoglu K, Karadeli E, et al. A case of brucellosis with abscess of the iliacus muscle, olecranon bursitis, and sacroiliitis. Int J Infect Dis. Apr 23 2009;[Medline].
Malkin J, Shrimpton A, Wiselka M, et al. Olecranon bursitis secondary to Mycobacterium kansasii infection in a patient receiving infliximab for Behcet's disease. J Med Microbiol. Mar 2009;58:371-3. [Medline].
Blankstein A, Ganel A, Givon U, et al. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. Dec 2006;27(6):568-71. [Medline].
Floemer F, Morrison WB, Bongartz G, et al. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. Jul 2004;183(1):29-34. [Medline]. [Full Text].
Tran N, Chow K. Ultrasonography of the elbow. Semin Musculoskelet Radiol. Jun 2007;11(2):105-16. [Medline].
Olsen NK, Press JM, Young JL. Bursal injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
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.
Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. Aug 2006;72(4):400-3. [Medline].
Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis. Feb 1984;43(1):44-6. [Medline]. [Full Text].
Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. Dec 1 2002;66(11):2097-100. [Medline].
Green SM. Nonsteroidal anti-inflammatory drugs (NSAIDs). In: Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon; 2000:11-2.
Friedman ND, Sexton DJ. Bursitis due to Mycobacterium goodii, a recently described, rapidly growing mycobacterium. J Clin Microbiol. Jan 2001;39(1):404-5. [Medline]. [Full Text].
Brinker MR, Miller MD. The adult elbow. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:153-64.
Lennard TA. Fundamentals of procedural care. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
McGee DJ. Elbow joints. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:143-67.
Morgan WJ. Elbow and forearm. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:70-98.
Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.
Further Reading
Related eMedicine topics:
Bursitis [Emergency Medicine]
Bursitis [Orthopedic Surgery]
Gout [Ophthalmology]
Gout [Orthopedic Surgery]
Gout [Radiology]
Gout [Rheumatology]
Gout and Pseudogout
Olecranon Bursa Aspiration
Olecranon Bursitis [Sports Medicine]
The Approach to the Painful Joint
Clinical guidelines:
ACR Appropriateness Criteria® chronic elbow pain. American College of Radiology - Medical Specialty Society. 1998 (revised 2008). 8 pages. NGC:006997
Elbow (acute & chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 May 28). 161 pages. NGC:006555
Elbow disorders. American College of Occupational and Environmental Medicine - Medical Specialty Society. 1997 (revised 2007). 67 pages. NGC:005681
Keywords
olecranon bursitis, bursitis olecranon, bursitis, bursitis elbow, elbow bursitis, elbow bursa, bursa elbow, septic bursitis, posterior elbow swelling, draftsman's elbow, student's elbow, miner's elbow
