Olecranon Bursitis 

Updated: Oct 04, 2018
Author: J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR; Chief Editor: Stephen Kishner, MD, MHA 

Overview

Practice Essentials

Olecranon bursitis, a relatively common condition, is inflammation of the subcutaneous synovial-lined sac of the bursa overlying the olecranon process at the proximal aspect of the ulna (see the images below).[1] The bursa cushions the olecranon and reduces friction between it and the skin, especially during movement. The superficial location of the bursa, between the ulna and the skin at the posterior tip of the elbow, makes it susceptible to inflammation from acute or repetitive (cumulative) trauma. Less commonly, inflammation results from infection (septic bursitis). Many cases are idiopathic, however. (See Etiology, Workup, Treatment, and Medication.)[1, 2, 3, 4, 5, 6]

Olecranon bursitis, shown here with the elbow flex Olecranon bursitis, shown here with the elbow flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Olecranon bursitis seen with the elbow extended; t Olecranon bursitis seen with the elbow extended; the focal olecranon swelling is more visible than it is when the elbow is flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Olecranon bursitis seen with the elbow extended. I Olecranon bursitis seen with the elbow extended. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

Workup

Usually, laboratory studies are necessary only if the clinician suspects that an underlying condition is present. 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 culture, for a cell count (white blood cells [WBCs], red blood cells [RBCs]), and for immediate Gram staining for bacteria.

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.[7]

Plain 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.

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 area by rapidly demonstrating the presence of effusions, synovial proliferation, loose bodies, increased blood flow consistent with inflammation, tendonitis with calcifications, and other indications of bursitis.[8]

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.[9]

Management

In general, physical and occupational therapy are not needed for the treatment of olecranon bursitis. In some cases of nonseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed recovery time.

In the absence of infection, most cases of olecranon bursitis respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with additional treatment.

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) can help to reduce the pain and inflammation of olecranon bursitis, but these products probably should be avoided if joint aspiration reveals a hemorrhagic bursitis. Injectable corticosteroid can be beneficial in cases in which the history, physical examination, and joint aspiration do not raise a significant suspicion of infection.[10]

Usually, no surgical intervention is required in cases of olecranon bursitis.[11] If the patient's condition becomes severe and does not respond to conservative treatment, however, bursectomy may be indicated.

If surgical intervention is required, endoscopic olecranon bursal excision is an effective alternative to open incision in either aseptic or septic cases. Endoscopic outcomes are excellent and can minimize wound-healing problems.[12]

Etiology

The bursa allows the skin to glide freely over the olecranon process, thereby preventing tissue tears. As previously stated, the superficial location of the olecranon bursa makes it susceptible to inflammation from acute or repetitive trauma.

Acute injuries during sports activities can include any action that involves direct or repetitive minor trauma to the posterior elbow (eg, landing on the olecranon process during a fall onto a hard floor or an artificial-turf playing field).

Common causes of olecranon bursal inflammation that are unrelated to sports activities include repetitive microtrauma (eg, the elbow constantly rubbing against a table during writing).

Bursal infection, a less common cause of olecranon bursitis, can result from abrasion or laceration at the affected site or from seeding from hematogenous spread via bacteremia. Inflammation can also be cause by a systemic inflammatory process (eg, rheumatoid arthritis) or a crystal-deposition disease (eg, gout, pseudogout). Patients are also at increased risk if they have diabetes mellitus, uremia, a history of intravenous drug abuse, alcohol abuse, or long-term use of steroids.[13, 14, 15, 16, 17, 18]

In patients on long-term hemodialysis treatment, uremia or a mechanical insult (such as resting the posterior elbow during hemodialysis treatment) is thought possibly to cause bursitis.[19] Inflammation of the bursa can also be an adverse effect of the drug sunitinib, which is used to treat patients with renal cell carcinoma.[20]

Larsen et al reported a case of bacillus Calmette-Guérin (BCG) olecranon bursitis developing from disseminated BCG infection, the result of BCG treatment for superficial bladder cancer.[21]

A retrospective study by Schermann et al of olecranon bursitis in the Israel Defense Forces found the condition to be more prevalent in combat units than in noncombat units, with most of the diagnoses being made during those periods of the year, summer and autumn, when training is particularly intensive. The investigators stated that the relatively high number of olecranon bursitis cases diagnosed during those months is probably related to outdoor training that requires crawling and suggested that the use of protective gear could alleviate the problem.[22]

Prognosis

In the absence of infection, most cases of olecranon bursitis respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with additional treatment. Some patients may experience recurrence of olecranon bursitis, in which even a relatively minor bump causes a significant effusion to return at this site.

Complications

Complications of olecranon bursitis include progressive or persistent pain with associated difficulty in using the affected upper extremity. Potential complications of aspiration/injection include the following:

  • Bleeding

  • Bruising

  • Allergic reaction (to the corticosteroid)

  • Swelling - This may recur, particularly if the patient does not maintain adequate pressure or icing at the site or if an infection was present at the time of the initial aspiration

  • Infection - The clinician should use appropriate techniques, including aseptic techniques, to minimize the chance of iatrogenic infection

  • Persistent drainage through the injection tract

  • Ulnar nerve injury - This theoretically may occur if a medial approach is used for the aspiration/injection

  • Transient elevation of blood glucose levels - This may occur after corticosteroid injection in a diabetic patient

  • Cardiac arrhythmia - This potentially can result from intravascular injection, due to the local anesthetic component

  • Peripheral nerve dysfunction - This is possible if the injection is administered near or within a major nerve

  • Compromised wound healing

  • Gastric, hepatic, and renal adverse effects from NSAIDs and narcotic analgesics

Patient Education

The patient should be educated regarding olecranon bursitis’s diagnosis, causative factors, and treatment plan. The most important aspect of patient education is ensuring that the patient knows to immediately report any signs or symptoms of persistent drainage or infection, particularly if a corticosteroid injection has been given. Diabetic patients should be told that they may experience a transient increase in blood glucose levels.

Patients should be informed that a corticosteroid usually does not begin to provide symptomatic improvement until a few days after the injection. Patients should also understand that they may experience a mild, transient increase in symptoms during the window of time when the local anesthetic has worn off but the steroids have not begun to have a therapeutic effect. For patient education information, see the Arthritis Center, as well as Bursitis.

 

Presentation

History

Patient history may include the following findings:

  • Focal swelling at the posterior elbow is usually noticed by the patient

  • The patient may report pain at the affected site, although sometimes the swelling is painless, especially in noninflammatory, aseptic bursitis

  • Pain often is exacerbated by pressure, such as when the patient leans on the elbow or when the patient rubs the elbow against a table while writing with the ipsilateral hand or with associated prolonged elbow flexion over 90°

  • Chronic, recurrent swelling usually is not tender; swelling may have gradual (mostly due to a chronic cause) or acute/sudden (due to trauma or infection/inflammation) onset

  • Frequent bumping of the swollen elbow may occur because the elbow protrudes further than normal

  • The patient may report a history of isolated trauma (eg, contusion) or repetitive microtrauma (such as constant rubbing of the elbow against a table while writing)

  • The onset may be sudden if the condition is secondary to infection or acute trauma

  • The onset may be gradual if olecranon bursitis is secondary to chronic irritation

Physical Examination

The most classic finding in olecranon bursitis is posterior elbow swelling that is often fluctuant and that is very clearly demarcated, appearing as a goose egg over the olecranon process (see the image below).

Olecranon bursitis seen with the elbow extended; t Olecranon bursitis seen with the elbow extended; the focal olecranon swelling is more visible than it is when the elbow is flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

Other findings in olecranon bursitis include the following:

  • The affected site may be tender to palpation; pain is variable; severe pain is often due to a traumatic or infectious cause; pain with pressure on the tip of the elbow may interfere with sleep

  • The area may be warm and red, particularly with infection

  • Skin inspection may reveal abrasion or contusion if trauma recently occurred

  • Vital signs may reveal fever, but generally only with advanced infection.

  • Elbow range of motion (ROM) usually is normal, but occasionally the end range of elbow flexion is slightly limited because of pain or, in chronic cases, due to bursal thickening; this decreased ROM may interfere with performance of basic activities of daily living, such as dressing, bathing, and grooming

  • Patients with systemic inflammatory processes (eg, rheumatoid arthritis) or a crystal deposition disease (eg, gout, pseudogout) may reveal evidence of focal inflammation at other sites or extending distally in the forearm if there is an associated cellulitis

  • Upon inspection of the elbow, rheumatoid nodules may be found in patients with rheumatoid arthritis (see the image below); firm “bumps” or “lumps”, due to residual scar tissue, may be felt as swelling recedes, especially when the elbow is bumped

  • Sensation should not be impaired, distal pulses should be intact, and other joints should not be affected

    Rheumatoid arthritis. Rheumatoid nodules at the el Rheumatoid arthritis. Rheumatoid nodules at the elbow. Photograph by David Effron MD, FACEP
 

DDx

Diagnostic Considerations

If there is a history of trauma, elbow pain during active or passive ROM may increase the clinician's suspicion of fracture of the olecranon process. Other conditions to consider in the differential diagnosis of olecranon bursitis include the following:

  • Crystalline inflammatory arthropathy (eg, gout, pseudogout)

  • Fracture of the olecranon process of the ulna

  • Synovial cyst of the elbow joint

  • Olecranon traction osteophyte (with or without avulsion)

  • Olecranon spur (usually without joint effusion)

  • Presence of infection (the most important consideration)

  • Triceps tendinitis/tear

  • Lipoma

Differential Diagnoses

 

Workup

Approach Considerations

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.[7]

Gram Stain

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 culture, for a cell count (WBCs, red blood cells [RBCs]), and for immediate Gram staining for bacteria. If the Gram stain is positive for bacteria, antibiotics should be started immediately and no corticosteroids should be injected into the bursa.

However, even if the Gram stain is negative or initially unavailable, withholding corticosteroid injection and starting 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).

WBC Count and Bacterial Culture

WBC count

The leukocyte count can help to determine whether the fluid is infectious or merely inflammatory.[7] Within synovial aspirates, WBC counts are assessed as follows:

  • Normal - Less than 200/µL

  • Noninflammatory - 200-2000/µL

  • Indication of inflammation - Count in the range of 2000-100,000/µL

  • Indication of a septic condition - Count greater than 100,000/µL

Bacterial culture

Bacterial culture and sensitivity testing of the aspirate can 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.

Other findings

After an acute injury, blood may be found within the aspirate, indicating a hemorrhagic bursitis (see the image below).

Aspiration of a hemorrhagic effusion in a patient Aspiration of a hemorrhagic effusion in a patient with olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

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 revealing needles of u Gout. Polarizing microscopy revealing needles of urate.

Imaging Studies

Radiography

Plain 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. Olecranon fracture.
Gout. Radiograph of erosions with overhanging edge Gout. Radiograph of erosions with overhanging edges.

Ultrasonography

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 area by rapidly demonstrating the presence of effusions, synovial proliferation, loose bodies, increased blood flow consistent with inflammation, tendonitis with calcifications, and other indications of bursitis.[8]

Magnetic resonance imaging

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, especially if there is a long history of septic bursitis or to evaluate an unusual mass seen on plain radiographs.[9]

Bursal Aspiration

The olecranon bursa can be aspirated using a long 18-gauge needle that is inserted after sterile skin preparation, using a circular motion with an antibacterial solution (after determining no applicable allergies exist) and appropriate local infiltration with a suitable agent, such as 1% lidocaine, using sterile technique to avoid secondary infection and a 27- to 30-gauge needle to make a skin wheal over the lateral bursa. The 18-gauge needle is attached to a 10-mL syringe and inserted into the dependent area of the bursa 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. The medial approach to the olecranon bursa should be avoided, since a misdirected needle could damage the ulnar nerve. Aspiration of bursal contents is continued until the bursal site is flat. The needle is then withdrawn and the wound dressed with adhesive sterile bandage and the elbow wrapped with a compressive dressing. Active elbow range of motion should be restricted for about 2 days post injection. (See the images below.)[13, 14, 15]

Olecranon bursogram. This image shows a needle inj Olecranon bursogram. This image shows a needle injecting contrast material into the olecranon bursa, under fluoroscopic guidance. Although olecranon bursa aspiration/injection usually does not require fluoroscopy or contrast, employing fluoroscopy here has demonstrated the outline of the involved bursa. Image ©2005, by Patrick M. Foye, MD, UMDNJ: New Jersey Medical School.
Needle aspiration in olecranon bursitis. Image cou Needle aspiration in olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
After fluid is removed from the olecranon bursa, a After fluid is removed from the olecranon bursa, an elastic, tubular compressive sleeve can be used to minimize reaccumulation of the fluid. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

If any cloudy fluid is aspirated, it should be sent for immediate Gram stain, leukocyte count, culture, and antibiotic sensitivity testing. No corticosteroids should be given until these tests prove negative. Aspiration can also be therapeutic, because it relieves the swelling. If cultures of aspirated fluid are negative and fluid recurs, the bursal aspiration can be repeated and, if sterile on culture, corticosteroids can be considered for joint injection.

If the clinician is confident that no infection is present, corticosteroid injection can be considered (for instance, immediately after aspiration of the fluid).[23]

In the absence of a traumatic etiology, consideration should be given to analyzing the aspirated fluid for infection and crystals.

When aspiration/injection is performed, aseptic techniques should be used to minimize the chance of causing iatrogenic infection. Septic olecranon bursitis due to Mycobacterium smegmatis has been reported after intrabursal steroid injection.[24]

 

Treatment

Approach Considerations

The patient’s physical condition and history should be taken into account when administering treatment for olecranon bursitis, as in the following cases:

  • Pregnant patient - Aspiration of the bursa and corticosteroid injection can be performed during pregnancy; oral nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided

  • Elderly patient with history of side effects from NSAIDs - It is necessary to be cautious when using NSAIDs in elderly patients; cyclo-oxygenase-2 (COX-2) inhibitors may be indicated

  • Patient with diabetes - Some patients with diabetes may experience a transient elevation in blood glucose levels after corticosteroid injection

In general, physical and occupational therapy are not needed for the treatment of olecranon bursitis. In some cases of nonseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed recovery time.

Usually, no surgical intervention is required in cases of olecranon bursitis.[11] If the patient's condition becomes severe and does not respond to conservative treatment, however, bursectomy may be indicated. Based on a literature review, Baumbach et al suggested that even in cases of septic olecranon bursitis, the evidence supports the initial use of conservative treatment rather than immediate bursectomy. They state that only patients with severe, refractory, chronic/recurrent olecranon bursitis should be treated via incision, drainage, or bursectomy. (They came to the same conclusions for prepatellar bursitis as well.)[25]

If surgical intervention is required in olecranon bursitis, endoscopic olecranon bursal excision is an effective alternative to open incision in either aseptic or septic cases. Endoscopic outcomes are excellent and can minimize wound-healing problems.[12]

A study by Ogilvie-Harris and Gilbart demonstrated that endoscopic bursal resection relieves pain symptoms and typically gives satisfactory results in patients with chronic olecranon bursitis.[26, 27]

A study by Meric et al also reported good results from endoscopic bursectomy, for either prepatellar or olecranon bursitis. The 49 patients in the study, including 30 with olecranon bursitis and 19 with prepatellar bursitis, were treated endoscopically (25 patients) or with open bursectomy (24 patients). At follow-up, the endoscopic group scored 8.5 on a patient satisfaction questionnaire, compared with 5.3 by the open surgery group.[28]

A study by Uçkay et al suggested that for adult patients with moderate to severe septic olecranon bursitis, the rate of wound dehiscence is lower with one-stage bursectomy than with a two-stage approach to the procedure. The investigators found that 1 out of 66 patients in the one-stage group experienced wound dehiscence, compared with 9 out of 64 in the two-stage group.[29]

Prevention

A compressive elbow sleeve (eg, a neoprene or elastic sleeve) may help to prevent the bursal fluid from reaccumulating after aspiration, but the application of excessive pressure over the elbow should be avoided.

Avoiding further trauma to the olecranon bursa is the key to recovery and prevention of recurrence. Consider use of elbow pads to cushion the elbow.

For cases of olecranon bursitis in which there is repeated recurrence, consider use of a posterior plaster splint to limit elbow motion for 1-2 weeks following aspiration. For severely recalcitrant cases, consider referral to an orthopedic surgeon for possible bursal excision.

Monitoring

The patient should return for reevaluation within approximately 2 weeks after treatment. At that time, assessment should be made regarding reaccumulation of fluid, persistent drainage, and signs of infection.

Activity

The athlete with olecranon bursitis may be expected to return to play without restrictions after he/she has demonstrated resolution of symptoms and of any positive physical examination findings (eg, swelling, tenderness to palpation) and has shown adequate performance in sports-specific practice drills without recurrence of symptoms or physical examination findings.

Aspiration

As previously mentioned, in the absence of infection most cases of olecranon bursitis respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with additional treatment.

A retrospective study by Weinstein and colleagues showed that in 47 patients with traumatic olecranon bursitis, almost all cases resolved via aspiration, with or without intrabursal glucocorticoid injection.[30] In the 25 patients who did receive glucocorticoid injection (20 mg of triamcinolone) in addition to bursal aspiration, the bursitis resolved much more rapidly than it did in the other patients, usually within 1 week. However, there seemed to be an association between the glucocorticoid injections and the development of complications, such as infection and skin atrophy.

A study by Kim et al reported that in the treatment of nonseptic olecranon bursitis, no difference in efficacy was found between the use of aspiration, the use of aspiration combined with steroid injections, and the use of compression bandaging combined with nonsteroidal anti-inflammatory drugs (NSAIDs), at 4-week follow-up. The investigators cautioned, however, that the study, which involved 83 patients, was powered to identify no less than a 30% difference between the three treatments, which means that if a smaller difference in efficacy existed, it may not have been detected.[31]

Pharmacologic Therapy

Oral NSAIDs can help to reduce the pain and inflammation of olecranon bursitis, but these products probably should be avoided if joint aspiration reveals a hemorrhagic bursitis. Injectable corticosteroid can be beneficial in cases in which the history, physical examination, and joint aspiration do not raise a significant suspicion of infection.[10]

Focal corticosteroid injection may be an option, but only if the clinician is confident that no local infection is present.

The decision as to whether the patient should be treated with empiric antibiotics depends on the perceived likelihood of infection, as indicated by patient history, physical examination, and analysis of the bursal aspirate.

In a study of 343 episodes of infectious bursitis, including 237 episodes of olecranon bursitis and 106 of patellar bursitis, Perez et al found that 7 days or less of antibiotic treatment was as effective as antibiotic therapy lasting from 8 days to more than 2 weeks. The investigators also found that short-course antibiotic therapy was not associated with a recurrence of bursitis.[32]

Injection technique

The injection should be on the lateral side of the elbow, so as to avoid the ulnar nerve. The target injection site is the soft-tissue center of the triangle 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.[10, 30]

Corticosteroids should never be injected into a site that appears to be infected or through skin that appears to be infected.

 

Physical Therapy

As previously mentioned, although physical and occupational therapy are generally not needed for olecranon bursitis, in some nonseptic cases the physician may recommend a course of physical or occupational therapy to speed recovery time.

Individuals who exhibit olecranon bursitis often are advised to apply the RICE (rest, ice, compression, elevation) method of treatment. Icing of the posterior elbow for 15-20 minutes at a time, several times daily, is recommended during the acute period (2-5 days).

Physical therapy modalities (eg, phonophoresis, electrical stimulation) also may be helpful in further reducing pain and inflammation, although these modalities are not necessary for most patients.[33]

The therapist can also complete patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. For the patient who undergoes bursal excision (bursectomy), physical therapy may be recommended postoperatively for regaining or maintaining the elbow's ROM and strength.

Consultations

Consultation with a physiatrist (physical medicine and rehabilitation physician) or with another qualified musculoskeletal specialist may be considered by physicians without the training, comfort, or procedural office supplies necessary for joint aspiration.

Consultation with a rheumatologist may be helpful if the clinical findings are consistent with inflammatory arthropathy.

Consultation with an orthopedic surgeon is required if a fracture is present, if the patient has a very severe case of recalcitrant bursitis that requires excision (bursectomy), or if incision and drainage are required for septic bursitis.

 

Medication

Medication Summary

Medications are used in cases of olecranon bursitis primarily to decrease pain and inflammation. Thus, the most commonly used medications are oral NSAIDs and focal corticosteroid injection, in conjunction with the rest of the rehabilitation plan.[10]

As previously stated, however, oral NSAIDs probably should be avoided if joint aspiration reveals a hemorrhagic bursitis. Injectable corticosteroid can be beneficial in cases in which the history, physical examination, and joint aspiration do not raise a significant suspicion for infection.

Empiric antibiotic selection is based on the suspected source of the microorganisms (local invasion by skin flora via puncture or abrasion, or hematogenous spread from a primary infection at another body site). Initial antibiotic selection is also directed by the results of the Gram stain of the aspirate.

Antibiotic treatment may start with a broad-spectrum antibiotic; then, when the culture and sensitivity test results are available, the antibiotic regimen may be modified as appropriate.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Class Summary

NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used. The choice of an agent is largely based on its adverse-effect profile, as well as on convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects), patient preferences, and cost.

Although increased treatment cost can be a negative factor, the incidence of costly and potentially fatal gastrointestinal (GI) bleeds is clearly less with cyclo-oxygenase-2 (COX-2) inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance in cases of GI bleeds will further define the populations that will find COX-2 inhibitors to be the most beneficial.

Ibuprofen (Motrin, Advil, Addaprin, Caldolor)

Ibuprofen is the drug of choice for mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available, either with or without a prescription.

Celecoxib (Celebrex)

Celecoxib inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, the COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.

Naproxen (Anaprox, Naprelan, Naprosyn)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase (COX), which is responsible for prostaglandin synthesis.

Ketoprofen

Ketoprofen is used for the relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with small body size, elderly patients, and persons with renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Corticosteroids

Class Summary

In contrast to the widespread, systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. A variety of corticosteroid preparations are available for injection. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Various local anesthetic agents also are available.

Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, A-Methapred)

Corticosteroids, such as methylprednisolone, are commonly used for local injections of bursae or joints to provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.

Methylprednisolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Dexamethasone (Baycadron)

Dexamethasone may reduce steroid hormone production. It decreases immune reactions. Dexamethasone provides a local anti-inflammatory effect while minimizing some of the gastrointestinal and other risks associated with systemic medications.

 

Questions & Answers

Overview

What is olecranon bursitis?

What is the role of lab studies in the workup of olecranon bursitis?

What is the role of plain radiographs in the workup of olecranon bursitis?

What is the role of ultrasonography in the workup of olecranon bursitis?

What is the role of MRI in the workup of olecranon bursitis?

What is the role of physical and occupational therapy in the treatment of olecranon bursitis?

What are the treatment options for olecranon bursitis in the absence of infection?

What is the role of oral NSAIDs in the treatment of olecranon bursitis?

When is surgery indicated for olecranon bursitis?

What is the etiologic relationship between the bursa and olecranon bursitis?

Which acute injuries are associated with olecranon bursitis?

What are common causes of olecranon bursitis other than sports-related injuries?

What are the causes of bursal infection associated with olecranon bursitis?

Why is olecranon bursitis associated with dialysis?

What is the etiologic relationship between bacillus Calmette-Guérin (BCG) and olecranon bursitis?

Why is olecranon bursitis more prevalent in combat units?

What is the prognosis of olecranon bursitis?

What are potential complications of olecranon bursitis?

What is included in the patient education information for olecranon bursitis?

Presentation

Which features of the patient history are consistent with olecranon bursitis?

What is the most classic finding in olecranon bursitis?

Which physical exam findings are associated with olecranon bursitis?

DDX

Which conditions are considered in the differential diagnosis of olecranon bursitis?

What are the differential diagnoses for Olecranon Bursitis?

Workup

What is the role of lab studies in the workup of olecranon bursitis?

What is the role of Gram stain in the workup of olecranon bursitis?

How are WBC counts interpreted in the workup of olecranon bursitis?

What is the role of bacterial culture in the workup of olecranon bursitis?

What findings besides infection can be revealed in the aspirate of olecranon bursitis?

What is the role of plain radiographs in the workup of olecranon bursitis?

What is the role of ultrasonography in the workup of olecranon bursitis?

What is the role of MRI in the workup of olecranon bursitis?

How is a bursal aspiration performed in the workup of olecranon bursitis?

Which lab studies are indicated when cloudy fluid is aspirated in olecranon bursitis?

When is corticosteroid injection administered following bursal aspiration in the workup of olecranon bursitis?

When is lab analysis of aspirated fluid indicated in the workup of olecranon bursitis?

How should aspiration/injection be performed in the workup of olecranon bursitis?

Treatment

Which patient conditions should be considered in the treatment of olecranon bursitis?

How can dehiscence be avoided in the surgical treatment of olecranon bursitis?

When is physical or occupational therapy indicated in the treatment of olecranon bursitis?

When is surgical intervention indicated in the treatment of olecranon bursitis?

When is endoscopic olecranon bursal excision indicated in the treatment of olecranon bursitis?

What is the postsurgical care following aspiration for olecranon bursitis?

What is the follow-up care after aspiration for olecranon bursitis?

What are the activity restrictions for patients with olecranon bursitis?

What is the role of aspiration in the treatment of olecranon bursitis?

What is the role of NSAIDs in the treatment of olecranon bursitis?

When is focal corticosteroid an option for the treatment of olecranon bursitis?

When is empiric antibiotic therapy indicated in the treatment of olecranon bursitis?

How is corticosteroid injection performed in the treatment of olecranon bursitis?

When is corticosteroid injection contraindicated in the treatment of olecranon bursitis?

What is the role of physical or occupational therapy in the treatment of olecranon bursitis?

How is the RICE method used in the treatment of olecranon bursitis?

When is physical therapy indicated in the treatment of olecranon bursitis?

When is specialist consultation indicated in the treatment of olecranon bursitis?

Medications

When are medications use for the treatment of olecranon bursitis?

When are NSAIDs contraindicated in the treatment of olecranon bursitis?

What is the role of empiric antibiotic therapy in the treatment of olecranon bursitis?

Which medications in the drug class Corticosteroids are used in the treatment of Olecranon Bursitis?

Which medications in the drug class Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are used in the treatment of Olecranon Bursitis?