Olecranon Bursitis

Original Editor ­ Racheal lowe Top Contributors - Sheik Abdul Khadir, Marlies Verbruggen, Rachael Lowe and Dieter Desmet ­ 


Definition/Description

                 Olecranon bursitis is a condition in which there is an inflammation of the bursr overlying the olecranon process at the proximal aspect of the ulna. [1][2] The superficial location of the bursa, namely between the ulna and the skin is susceptible to inflammation from a variety of mechanisms, primarily either acute or repetitive trauma. It is also possible that the inflammation is due to infection, called septic bursitis. Two-thirds of the cases are bursitis without an infection or nonseptic bursitis. [3] Nevertheless this type of bursitis is less common. [1][2]

                 However the olecranon bursa normally provides a mechanism with which the skin can glide freely over the olecranon process, consequently the bursa prevents tissue tears.[1]

Epidemiology/Etiology

                     Olecranon bursitis is a condition which is relatively common. There is no mortality associated with this condition. It is possible that the pain at the posterior elbow may cause morbidity, with limitation of some functional activities (e.g. writing). Although the overall incidence is not known, it typically affects men between the ages of 30 and 60 years. Two-thirds of cases are nonseptic (ie, without infection) and usually occur when trauma or repeated small injuries lead to bleeding into the bursa or release of inflammatory mediators.[4]

                      There is no predisposition for race or sex. Olecranon bursitis occurs with children and adults. Long-term hemodialysis treatment , uremia or a mechanical factor (like resting the posterior elbow during a hemodialysis treatment) can be a cause of inflammation. [1] This condition can be caused by acute injuries (trauma) during sports activities because they can include any action that involves direct trauma to the posterior elbow. For example falling onto a hard floor et cet.

                       Other common causes of olecranon bursitis, which are not related to sports activities, include repetitive microtrauma, like rubbing constantly the elbow against a table during writing.[1][2] Such a trauma or those repeated small injuries lead to bleeding into the bursa or the release of inflammatory mediators. [3] People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows.[5]Finally inflammation may be due to a systematic inflammatory process, like rheumatoid arthritis, or a crysal deposition disease, like gout and pseudogout. [1][2][6] This condition can also be a side-effect of sunitinib, which is used to treat patients with renal cell carcinoma.[2].

History

  1. Patients usually remark a focal swelling at the posterior elbow. [1][2] the swelling is sometimes painless.
  2.  Pressure, like leaning on the elbow or rubbing against a table while writing with the ipsilateral hand, are factors which can often exacerbate the pain.
  3. Chronic recurrent swelling is usually not tender.
  4. A typical symptom of olecranon bursitis is the frequent bumping of the swollen elbow, because it protrudes further than it usually would.

                     It is possible that the patient reports a history of isolated trauma or repetitive microtrauma. The start may be sudden, when it is secondary to infection or acute trauma. When olecranon bursitis is secondary to chronic irritation, the onset will be more gradual. [1][2]

Clinically Relevant Anatomy

                     A bursa is a part of your body that allows two other parts to move smoothly together (outside of a joint). It’s a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone and are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts.
                    The olecranon bursa is located between the tip, or point, of the elbow (called the olecranon) and the overlying skin. This bursa allows the elbow to bend and straighten freely underneath the skin, but when the bursa gets irritated, the sac fills up with fluid which leads to swelling of the elbow tip.[7]

Clinical Presentation

  • Bursal inflammation’s most classic finding is a swelling, at the posterior elbow. This swelling is clearly marked off by its appearance as a goose egg over the olecranon process.[1][2][3]
  • There may be a tenderness for palpation at the affected site. Cases in which infection is present may show a warm and red affected area.
  • If the trauma has recently occurred, the inspection of the skin may reveal abrasion or contusion.
  • Generally a patient with advanced infection, can have fever.
  • The Range of motion (ROM) of the affected elbow is usually normal but now and then it is possible that the end-range of elbow flexion is slightly limited due to pain.
  • Patients suffering from systematic inflammatory processes (like rheumatoid arthritis) or crystal – deposition disease (like gout or pseudogout) may reveal evidence of focal inflammation at other sites. When you exam a patient who has rheumatoid arthritis, it is possible that you can see rheumatoid nodules during inspection of the elbow. If the patient reports elbow pain during active or passive ROM and if a history of trauma exists, this may increase the clinical suspicion of an olecranon process fracture.[1][2]

Diagnostic Procedures

Laboratory tests are essential to differentiate septic from non-septic bursitis when doubt remains after clinical examination, so the aspirate should be sent for microscopy and culture.
Blood tests are not usually helpful.
If there is any doubt about the diagnosis then treatment should be given as for a septic case until culture results are available.[8][9]

Differential Diagnosis

Rheumatoid arthritis [1]
Elbow and forearm overuse injuries[2]
Gout[2]
Gout and pseudogout[2]
Olecranon fractures[2]
Triceps tendon avulsion[2]

Physical therapy management

Level of evidence D :


Most of the time physical and occupational therapy are not necessary, but are often indicated to reduce recovery time. Patients who have often olecranon bursitis are recommend to apply the RICE method of treatment. Rice stands for Rest, Ice, Compression and Elevation. There are also other physical therapy modalities that could be helpful for reducing pain and inflammation. For example phonophoresis, electrical stimulation. However, most patients with olecranon bursitis don’t necessary need those modalities. The physical therapist can also take care of the patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. When the patient shows no response to conservative treatment and his condition deteriorates, then surgery may be indicated. When a patient undergoes a bursal excision (bursectomy), there might be a recommendation for physical therapy after the operation for regaining or maintaining the ROM and strength of the elbow. [1][2]


Non-surgical treatment

Step 1 involves aspiration of the bursa with an 18-gauge needle. In step 2, a mixture of 80-mg methylprednisolone and 2% lidocaine (specifically 1 mL of methylprednisolone and 1.5 mL of lidocaine without adrenaline) is injected into the elbow joint from a lateral approach. Step 3 involves the application of a dry gauze dressing, followed by the application of a tensor bandage or elbow brace for a period of 3 to 6 months.


The technique was discovered over 3 to 4 years, with 4 or 5 cases being treated per month. Follow-up with each patient occurred at 2 weeks, 3 months, and 6 months. At each follow-up visit, side effects, pain assessment, and limitation of function (including warmth, degree of swelling, and tenderness) were assessed and recorded. The typical pain, skin atrophy, and corticosteroid-induced side effects mentioned by some authors1–5 were not observed in any of these cases. In addition, none of my patients who used this technique developed septic bursitis or tendon rupture. My experience with this technique has been rewarding— efficiency rates range from approximately 95% to 100%.


Other treatments that have been suggested in the past for nonseptic olecranon bursitis include the following1–5:

  1. bursal aspiration alone, with or without compressive dressings;
  2. conservative approach;
  3. nonsteroidal anti-inflammatory drugs for 10 to 14 days;
  4. corticosteroid injections alone, after aspiration;
  5. a “blood patch” injection;
  6. the temporary 3-day use of a percutaneous-intrabursal drainage catheter;
  7. holding a needle in place with a hemostat, if aspirating and injecting;
  8. intrabursal injections of tetracycline and talcum powder. However, from my clinical experience, these treatments are not as effective as the 3-step technique I have described above.[10]


Surgical Treatment

Surgery for infected bursa


If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery to remove the entire bursa may be needed. This is often an inpatient procedure, meaning you will need to stay overnight in the hospital. This surgery may be combined with further use of oral or intravenous antibiotics.
The bursa usually grows back as a non-inflamed, normally functioning bursa over a period of several months.


Surgery for noninfected bursa


If elbow bursitis is not a result of infection, surgery may still be needed if nonsurgical treatments do not work. In this case, surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structures.


Recovery


Your doctor will apply a splint to your arm after the procedure to protect your skin. In most cases, casts or prolonged immobilization are not necessary.
Although formal physical therapy after surgery is not usually needed, your doctor will recommend specific exercises to improve your range of motion. These are typically permitted within a few days of the surgery.
Your skin should be well healed within 10 to 14 days after the surgery, and after 3 to 4 weeks, your doctor may allow you to fully use your elbow. Your elbow may need to be padded or protected for several months to prevent re-injury.[11]

Recent Related Research (from Pubmed)

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.Foye PM. Et al., Physical Medicine and Rehabilitation for olecranon bursitis. 2009, sept. 30, Medscape : http://emedicine.medscape.com/article/327951-overview (Level D)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.Foye PM. Et al., Olecranon bursitis . 2010, aug. 31, Medscape : http://emedicine.medscape.com/article/97346-overview (Level D)
  3. 3.0 3.1 3.2 4.Lockman L. treating nonseptic olecranon bursitis. Canadian Family Physician, 2010; 56 : 1157 (Level D)
  4. Stell IM. Septic and non–septic olecranon bursitis in the accident and emergency department—an approach to management. J Accid Emerg Med 1996;13(5):351-3. (3B)
  5. http://orhtoinfo.aaos.org/topic.cfm?topic=a00028
  6. 3.Herrera F.A. et al., Chronic olecranon bursitis. The journal of hand surgery, 2011; 36(4):708-9. (Level D)
  7. Bernard F. Morrey, M.D.,Joaquin Sanchez-Sotelo. The elbow and its disorders. Philadelphia: Saunders Elsevier, 2009, p11-58.
  8. Stell IM. Septic and non–septic olecranon bursitis in the accident and emergency department—an approach to management. J Accid Emerg Med 1996;13(5):351-3. (3B)
  9. http://orhtoinfo.aaos.org/topic.cfm?topic=a00028
  10. Treating nonseptic olecranon bursitis A 3-step teqchnique, Leonard Lockman, MB ChB M Fam Med(SA) MD CCFP (2B)
  11. http://orhtoinfo.aaos.org/topic.cfm?topic=a00028