OLECRANON BURSITIS

OLECRANON BURSITIS

Olecranon bursitis is inflammation of the bursa overlying the olecranon process at the proximal aspect of the ulna.

The bursa is located between the ulna and the skin at the posterior tip of the elbow.

PATHOPHYSIOLOGY

Normally, the olecranon bursa prevents tissue tears by providing a mechanism with which the skin can glide freely over the olecranon process.

Bursal inflammation may be caused by a variety of mechanisms. Owing to its superficial location, this bursa is susceptible to inflammation from either acute or repetitive (cumulative) trauma.

Less commonly, inflammation may result from infection (septic bursitis).

MORTALITY/MORBIDITY

• Generally, no mortality is associated with this condition.

• Pain at the posterior elbow may cause morbidity, limiting some functional activities, such as writing. Complications of aspiration/injection include recurrence, infection, and persistent drainage.

AGE

This condition occurs in children and adults. In patients on long-term hemodialysis treatment, uremia or a mechanical factor (such as resting the posterior elbow during hemodialysis treatment) is thought possibly to cause the inflammation.

CLINICAL

HISTORY

• 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.

• 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.

• Chronic recurrent swelling usually is not tender.

• Frequent bumping of the swollen elbow may occur because the elbow protrudes farther 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).

• Onset may be sudden if the condition is secondary to infection or acute trauma.

• Onset may be gradual if olecranon bursitis is secondary to chronic irritation.

PHYSICAL

• The most classic finding is posterior elbow swelling that is very clearly demarcated, appearing as a goose egg over the olecranon process.

• The affected site may be tender to palpation.

• 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 may be slightly limited because of pain.

• Patients with systemic inflammatory processes (eg, rheumatoid arthritis) or crystal deposition disease (eg, gout, pseudogout) may reveal evidence of focal inflammation at other sites.

• Upon inspection of the elbow, rheumatoid nodules may be found in patients with rheumatoid arthritis.

• 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.

CAUSES

• Acute trauma (such as falling onto a hard floor or a playing field with artificial turf and landing on the olecranon process)

• Minor cumulative trauma, such as repetitive rubbing of the olecranon region against a desktop during writing

• Infection resulting from abrasion or laceration at the site or owing to seeding from hematogenous spread by bacteremia

• Inflammation as part of a systemic inflammatory process (eg, rheumatoid arthritis) or a crystal deposition disease (eg, gout, pseudogout)

DIAGNOSIS

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.

• In rare cases, magnetic resonance imaging (MRI) may be indicated to exclude concomitant osteomyelitis or abscess formation.

PROCEDURES

• Bursal aspiration still remains the criterion standard to differentiate septic and aseptic olecranon bursitis.

  • 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).

TREATMENT

PHYSICAL THERAPY

In general, physical and occupational therapy are not needed for this condition.

In some cases of nonseptic bursitis, however, 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.

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 with this condition.

The therapist can also complete patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. If the patient's condition becomes severe and does not respond to conservative treatment, surgery may be indicated.

For the patient who undergoes bursal excision (bursectomy), physical therapy may be recommended postoperatively for regaining or maintaining the elbow's ROM and strength.

COMPLICATIONS

• Complications of the disease process include persistent pain and associated decreased functional use of the affected upper extremity.

• Potential complications of aspiration/injection are as follows:

  • 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

  • Persistent drainage through the injection tract

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

SURGICAL INTERVENTION

Usually, no surgical intervention is required; however, very severe cases of recalcitrant bursitis may require bursectomy.

OTHER TREATMENT

• Oral nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful.

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

  • 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. The 25 patients who did receive glucocorticoid injection (20 mg of triamcinolone) in addition to the bursal aspiration resolved much more rapidly, usually within 1 week. However, glucocorticoid injection seemed to be more highly associated with complications, such as infection and skin atrophy.

  • 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.

• A compressive elbow sleeve (eg, a neoprene or elastic sleeve) may help to prevent the bursal fluid from re-accumulating after aspiration.

MEDICATION

For this musculoskeletal condition, medications are used 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.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

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

IBUPROFEN (Motrin, Advil, Nuprin, Rufen)

DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult: 200-800 mg PO tid/qid

Pediatric:

<6 months: Not established

6 months to 12 years: 4-10 mg/kg/dose PO tid/qid

>12 years: Administer as in adults

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Minimize risks of adverse effects by not taking multiple NSAIDs concurrently; caution in patients on anticoagulants or systemic corticosteroids and with bleeding disorders or significant alcohol use; caution in aspirin/NSAID-induced asthma; hypertension, CHF, and advanced age 

NAPROXEN (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Adult: 500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d

Pediatric:

<2 years: Not established

>2 years: 2.5 mg/kg PO; not to exceed 10 mg/kg/d

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug 

KETOPROFEN (Oruvail, Orudis, Actron)

For relief of mild to moderate pain and inflammation.

Small doses are indicated initially in patients with small body size, elderly patients, and those with renal or liver disease.

Adult: 25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Doses >75 mg do not increase therapeutic effects; administer high doses with caution and closely observe patient for response

Pediatric:

<3 months: Not established

3 months to 12 years: 0.1 mg/kg PO q6-8h

>12 years: Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in CHF, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

Although increased cost can be a negative factor, the incidence of costly and potentially fatal gastrointestinal (GI) bleeds is clearly less with cyclooxygenase-2 (COX-2) inhibitors than with traditional NSAIDs.

Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial. 

CELECOXIB (Celebrex)

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, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.

Adult: 200 mg/d PO qd; alternatively, 100 mg PO bid

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results

CORTICOSTEROIDS

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 (Solu-Medrol, Medrol, Adlone)

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.

Adult: 40 mg (1 mL) intralesionally is common for injection at many sites, often mixed with a few mL of a local anesthetic, such as 1% lidocaine.