Laboratory Studies
Serum studies are usually only necessary in olecranon bursitis if the clinician suspects an underlying condition, which includes the following:[7]
- 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.[8] 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 the image 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 the image 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 the image below).
Olecranon fracture. The use of ultrasound 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 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.[10]
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 the image 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.[11]
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