Treatment Algorithm for Olecranon Bursitis

Introduction

The dorsum portion of the ulna is known as the olecranon and is covered by a synovium lined sac known as the olecranon bursa (Eli Sayegh, 2014). Olecranon bursitis is known as student’s elbow, businessman’s elbow, hemodialysis elbow, and many other pseudonyms (Bernard F. Morrey, 2018). Fluid accumulation, known as olecranon bursitis, is common with upwards of 10 cases per 100,000 patients (Joon Yub Kim, 776-783). The olecranon bursa is at risk for infection due to hits superficial location (Frank Floemer, 2004). Due to the challenge differentiating septic and nonseptic olecranon bursitis, we performed a review on the diagnosis and management of olecranon bursitis.

Clinical symptoms

Patients who present with olecranon bursitis typically report a history of elbow trauma, history of inflammatory condition, trauma, or have a pre-existing medical condition that has led to a degree of immunosuppression (Danielle Reilly, 2016; Bernard F. Morrey, 2018). Two conditions associated with olecranon bursitis are rheumatoid arthritis and gout (Bernard F. Morrey, 2018). The olecranon is typically distended on one side and can be tender in upwards of 45% of aseptic olecranon bursitis cases (Daniel Aaron, 2011).

Olecranon bursitis is typically nonseptic and is seen frequently in football players who play on artificial turf (Frank Floemer, 2004). The challenge is that 1/3 of the cases of olecranon bursitis can be septic (Frank Floemer, 2004). Of the septic bursa cases, there is a male predominance (Danielle Reilly, 2016).

Risk factors for developing a septic joint are impaired immunity, diabetes mellitus, CKD, chronic steroid use, and malignancy (Frank Floemer, 2004). It is difficult to differentiate nonseptic from septic olecranon bursitis based on clinical exam alone. Both conditions will typically present with bursa swelling, redness, and pain to palpation (Danielle Reilly, 2016). Pain with elbow motion does not suggest septic bursitis, as a large nonseptic bursa can cause pain due to peri-bursal pressures (Danielle Reilly, 2016). Septic bursitis is also associated with soft tissue edema within the brachium due to lymphangitis (Bernard F. Morrey, 2018).

Diagnostic work up

Due to the difficulty in differentiating septic olecranon bursitis from nonspetic bursitis, a fluid aspiration is the gold standard for confirming an infectious etiology (Danielle Reilly, 2016). The aspirated fluid should be sent for gram stain and culture, cell count, crystal analysis, and glucose (Danielle Reilly, 2016). Finding greater than 50% of polymorphs in the cell count is suggestive of a septic bursa (Danielle Reilly, 2016). A review published in the Archives of Orthopedic Trauma Surgery found that fluid aspirate with >3000 WBCs is suggestive of a septic olecranon bursa (Sebastian F Baumbach, 2014). There is no clear consensus on the WBC value that is suggestive of a septic bursa. The most common pathogen identified in septic olecranon bursitis is Staphylococcus aureus followed by Streptococcus (Eli Sayegh, 2014). In cases of a septic bursa, aspiration with gram stain has been found to only identify 50% of cases (Daniel Aaron, 2011). However, aspiration does not come without risk, as aspirating an olecranon bursa can cause a sinus tract from the skin to the bursa, which can lead to chronic drainage (Eli Sayegh, 2014).

Physicians should also consider checking ESR/CRP and leukocyte count, as elevated values can further support the diagnosis of septic bursitis (Sebastian F Baumbach, 2014).

Radiographs are typically performed as well to rule out any foreign body retention or bony pathology (Danielle Reilly, 2016).

MRI is not typically required to diagnose olecranon bursitis. However, in patients with signs of a worsening infection, an MRI can help evaluate for osteomyelitis or an abscess (Frank Floemer, 2004). A study in the American Journal of Roentgenology looked to see if MRI could help differentiate septic and nonseptic olecranon effusions with MRI. What they found was that there was not one MRI criteria (synovial thickening, joint effusion, synovial enhancement, marrow edema) that could successfully differentiate the two conditions due to the considerable radiographic overlap (Frank Floemer, 2004).