eMedicine Specialties > Sports Medicine > Upper Limb
Olecranon Bursitis: Differential Diagnoses & Workup
Updated: Mar 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Elbow and Forearm Overuse Injuries
Gout
Gout and Pseudogout
Olecranon Fractures
Triceps Tendon Avulsion
Other Problems to Be Considered
Fracture of the olecranon process of the ulna
Olecranon traction osteophyte (with or without avulsion)
Presence of infection (the most important consideration)
Rheumatoid arthritis
Synovial cyst of the elbow joint
Triceps tendinitis/tear
Workup
Laboratory Studies
- Serum studies are usually only necessary in olecranon bursitis if the clinician suspects an underlying condition, which includes the following6 :
- Infection (complete blood cell [CBC] count, including the differential count of white blood cells [WBCs], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR])
- Rheumatoid arthritis (rheumatoid factor, ESR, CRP)
- Gout (check uric acid level)
- If infection is suspected (due to the presence of fever, redness, previous puncture wounds, or cellulitis), the olecranon bursa should be aspirated and the fluid sent for immediate Gram staining for bacteria and cell count (WBCs, red blood cells), as well as cultures.
- An immediate Gram stain for bacteria is helpful to quickly determine if bacterial infection is present. If the Gram stain is positive for bacteria, antibiotics should be started immediately and no corticosteroids should be injected into the bursa.
- Even if the Gram stain is negative or initially unavailable, there are situations in which it may be prudent to avoid local corticosteroid injection, and, instead, start antibiotics immediately after the culture is obtained, to prevent worsening of the infection.7 For example, antibiotics may seem to be indicated based on the mechanism of injury (eg, abrasion or puncture), on the physical examination findings that are suggestive of infection (eg, fever, significant local redness and warmth), or on the gross appearance of the aspirated fluid (eg, turbid, purulent).
- The leukocyte count can be used to help determine if the fluid is infectious or merely inflammatory. Within synovial aspirates, WBC counts are classified as follows:
- Normal – Less than 200 WBCs/µL
- Noninflammatory – 200-2000 WBCs/µL
- Inflammatory – 2000-100,000 WBCs/µL
- Septic – More than 100,000 WBCs/µL
- Bacterial culture and sensitivity testing of the aspirate can then be performed to ensure the relevant bacteria are sensitive to the chosen antibiotic. These results can guide the modification of antibiotics in cases of bacterial infection.
- After an acute injury, blood may be found within the aspirate, indicating a hemorrhagic bursitis (see Image 5 or below).
Olecranon bursitis aspiration of a hemorrhagic effusion. Image ©2007, by Patrick M. Foye, MD, UMDNJ New Jersey Medical School.
- Analysis for crystals may reveal monosodium urate crystals in patients with gout, calcium pyrophosphate crystals in pseudogout, or hydroxyapatite crystals (see Image 10 or below).
Gout. Polarizing microscopy needles of urate.
Imaging Studies
- Radiographs of the elbow should be performed to assess for a possible olecranon fracture if significant trauma occurred or if an avulsed osteophyte is present at the triceps insertion into the olecranon, which is fairly common (see Image 9).
- In atypical cases, a magnetic resonance imaging (MRI) study may be indicated to help exclude concomitant pathology, such as a stress fracture, triceps tendinopathy or tear, or the rare case of osteomyelitis/abscess or tumor.8
Procedures
- Bursal aspiration remains the criterion standard to differentiate between septic and aseptic olecranon bursitis.
- The olecranon bursa can be aspirated using an 18-gauge needle that is inserted through a posterolateral approach, via an oblique needle angle or zigzag approach. As opposed to a direct, perpendicular approach that is used for most joint aspirations, this technique creates a longer needle tract through the skin and subcutaneous layers, thus minimizing the risk of fistula formation (see Image 4 or below).
Needle aspiration of olecranon bursitis. Image ©2007, by Patrick M. Foye, MD, UMDNJ New Jersey Medical School.
- Aspiration can be helpful diagnostically; any cloudy fluid should be sent for an immediate Gram stain and leukocyte count, as well as a culture, with tests for antibiotic sensitivity. No corticosteroids should be given until these tests prove negative.
- Aspiration can also be therapeutic because it relieves the swelling.
- If the clinician is confident that no infection is present, a corticosteroid injection can be considered (eg, immediately after aspiration of the fluid).
- The injection should be on the lateral side of the elbow to avoid the ulnar nerve. The target injection site is the soft-tissue center of the triangle that is formed by the lateral olecranon, the head of the radius, and the lateral epicondyle. As with most injections, the physician should first aspirate to ensure that the needle is not in a blood vessel, and then inject using a slow, but consistent pressure.9
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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Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:756-82.
Snider RK. Olecranon bursitis. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy Orthopedic Surgeons; 1997:156-9.
Morgan WJ. Elbow and forearm. In: Steinberg GG, Akins C, Baran D, eds. Orthopaedics in Primary Care. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:70-98.
Brinker MR, Miller MD. The adult elbow. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999:153-64.
Schumacher HR. Arthrocentesis, synovial fluid analysis, and synovial biopsy. In: Schumacher HR, Klippel JH, Koopman WJ, eds. Primer on the Rheumatic Diseases. 10th ed. Richmond, Va: Arthritis Foundation; 1993:67-72.
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].
Floemer F, Morrison WB, Bongartz G, Ledermann HP. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. Jul 2004;183(1):29-34. [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]. [Full Text].
Lennard TA. Fundamentals of procedural care. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
Ogilvie-Harris DJ, Gilbart M. Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy. Apr 2000;16(3):249-53. [Medline].
Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia. Loma Linda, Calif: Tarascon Publishing; 2000:11-12.
Olsen NK, Press JM, Young JL. Bursal injections. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
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].
Barham GS, Hargreaves DG. Mycobacterium kansasii olecranon bursitis. J Med Microbiol. Dec 2006;55(pt 12):1745-6. [Medline].
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. [Medline].
Damert HG, Altmann S, Schneider W. [Soft-tissue defects following olecranon bursitis: treatment options for closure] [German]. Chirurg. Aug 7 2008;epub ahead of print. [Medline].
Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. Aug 2006;72(4):400-3. [Medline].
Jin W, Lee JH, Yang DM, et al. Olecranon bursitis communicating with an olecranon cyst in rheumatoid arthritis. J Ultrasound Med. Jun 2007;26(6):857-61. [Medline].
Further Reading
Related eMedicine Topics
- Bursitis [in the Emergency Medicine section]
- Bursitis [in the Orthopedic Surgery section]
- Elbow and Forearm Overuse Injuries [in the Sports Medicine section]
- Overuse Injury [in the Physical Medicine and Rehabilitation section]
National Guidelines Clearinghouse
- Elbow (acute & chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 May 28). 161 pages. NGC:006555
- ACR Appropriateness Criteria® chronic elbow pain. American College of Radiology - Medical Specialty Society. 1998 (revised 2005). 5 pages. [NGC Update Pending] NGC:004605
Keywords
olecranon bursitis, bursitis, tendinitis, elbow pain, olecranon, student's elbow, draftsman's elbow, swollen/inflamed elbow, painful elbow
