Aspiration of Olecranon Bursa

When a bursa becomes inflamed, it may be categorized as either septic (infective) or aseptic (noninfective). 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.

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.

It should be recognized, however, that a clear diagnosis of cellulitis can be difficult, in that the findings of erythema, increased warmth, and tenderness may be local inflammatory changes rather than true peribursal cellulitis. 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]

Aspiration of of an inflamed olecranon bursa is performed to obtain fluid for analysis and to help distinguish noninfective (aseptic) bursitis from infective (septic) bursitis.

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

Whereas 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]

Contraindications for aspiration of the olecranon bursa include the following:

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

Equipment used in aspirating the olecranon bursa includes the following:

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

Anesthesia

Anesthesia is achieved with inject of a local anesthetic (see Technique). For more information, see Local Anesthetic Agents, Infiltrative Administration.

Positioning

Position the patient sitting upright on a stretcher. Rest the affected arm on a side table with the elbow flexed 90º (see the image below).

Standard technique

Identify the inflamed olecranon bursa, and select a needle insertion site (if possible, over noninflamed skin). The insertion site should be posterolateral to avoid the ulnar nerve that is located medially (see the image below). Do not insert the needle on an area of overlying cellulitis; doing so may result in infection of the bursa or joint. Insert in an area with the least amount of inflammatory changes.

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; allow the solution to dry before aspiration. Place a sterile drape on the side table, and ask the patient to lower the elbow back onto the sterile drape. Apply sterile drapes around the prepared skin (see the image below).

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

Arm a new 10-mL syringe with an 18-gauge 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 the image below).

Withdraw the needle (see the image below). Clean the skin, and place an adhesive bandage over the injection site.

Better sealing of the needle tract may be achievable with the Z-tract technique (see below).

Z-tract technique

To aspirate an inflamed olecranon bursa with the Z-tract technique, first follow the preparatory steps above, including positioning, sterile preparation, anesthesia, and landmark identification. Then, before inserting the needle, pull the skin overlying the needle insertion side either medially or laterally. This creates a longer subcutaneous needle tract and seals it better after the needle is removed.

After needle insertion, complete the aspiration procedure as described above.

Local infection is a rare complication that may 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. To minimize the risk of fistula formation, some authors recommend using the Z-tract technique (see Olecranon Bursa Aspiration).