Olecranon bursitis-Diagnosis,symptoms and Treatment

OLECRANON BURSITIS
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Olecranon bursitis

History

■ Causes

➣ Direct trauma–trauma to olecranon tip (i.e.,falling).

  • Common in football
  • Associated with artificial turf
  • Common in ice hockey due to elbowing and checking.

➣ Traumatic overuse

  • Repetitive trauma
  • Leaning on elbows

➣ Infectious or septic

  •  May have local trauma with secondary infection.
  • May co exist with other types of bursitis.

➣ Rheumatoid arthritis.

➣ Crystal line disease.

  •  Gout may predispose to infectious bursitis.
  • Calcium phosphate deposition disease.

Symptoms and presentation

➣ General symptoms

  • Swelling in olecranon bursa
  • Often acute change in size of bursa
  • Quite often painless,but annoying

➣ Symptoms associated with infection, rheumatoid arthritis, or crystal line disease.

  • Redness over olecranon
  • Swelling in to forearm
  • May have fever or malaise
  • Elbow stiffness
  • Drainage from bursa

Physical Exam

Localized  swelling over tip of olecranon.

Look for signs of external trauma.

➣ Folliculitis

➣ Ecchymosis

➣ Abrasions with surrounding cellulitis.

  • Especially important early.
  • Ice hockey players due to elbow pads.

Evaluate for signs of infection

➣ Warmth

➣ Pain more common in septic bursitis

➣ Erythema

➣ Cellulitis

➣ Swelling

Evaluate elbow range of motion

➣ Loss of motion more common in infectious or rheumatoid causes.

  • Pain limiting motion.
  • Connection of bursa with joint in rheumatoid patients.

Compare contra lateral elbow

➣ Loss of motion due to arthritis.

➣ Presence of bony spurs.

➣ Prominent olecranon tip.

➣ Presence of thickened bursa.

➣ Gouty to phior rheumatoid nodules.

Studies

Radiographs–helpful to exclude fractures in trauma.

➣ Soft tissue swelling

➣ Chondro calcinosis

➣ Olecranon spur associated with traumatic bursitis.

Little role for other adjunctive studies.

Blood work–not overly helpful for infection unless late.

Aspiration and fluid studies helpful in causation and treatment.

➣ Cultures.

➣ Analysis of crystals from aspiration.

Differential Diagnosis 

Olecranon bursitis–diagnosis usually easy and apparent.

Chondro calcinosis involving bursa.

Infection.

Trauma and fractures to olecranon or radial head.

Treatment

Acute non infectious bursitis

➣ Many cases resolve spontaneously.

➣ Local pads to prevent trauma.

➣ Decrease use; sling may help.

➣ Compressive wraps.

  • Neoprene elbow sleeve.
  • Ace wraps.

➣ Aspiration to rule out infection if etiology in doubt,if symptoms significant,or if prolonged.

➣ Corticosteroid injection after aspiration.

  • More effective resolution.
  • May unmask infection.

➣ Presumptive antibiotics for Staphylococcus aureus.

Acute septic bursitis

➣ Aspiration and antibiotics.

  • Aspiration for cell count,crystals,Gram stain,cultures.
  • Oral antibiotics for mild cases.
  • Cover for S.aureus.
  • IV antibiotics for severe or non responsive cases.
  • Generally need 10 days to 2 weeks treatment.

➣ Surgical drainage.

Chronic olecranon bursitis

➣ Serial aspiration.

➣ Treat for occult infection.

➣ Injection of corticosteroids into bursa.

Rheumatoid olecranon bursitis

➣ Bursa can communicate with elbow joint.

➣ Drainage can reflectinfected joint.

➣ More drainage than usual.

➣ Need to treat aggressively.

➣ Recurrence rate very high.

➣ Differentiate from rheumatoid nodules where ulceration common,recurrence common after  excision.

Indications for surgical drainage

➣ Failed aspiration and antibiotic treatment.

➣ Long standing infections,either recurrent or resistant.

➣ Previous infection,drainage,or surgery.

➣ Desire for removal of bursa.

Surgical treatment

➣ Attempt to clear up severe infection.

  • Antibiotics.
  • Local decompression and drainage.

➣ Longitudinal incision in skin.

➣ Excise all bursal tissue,which may extend proximally or distally.

  • Skin can be thin–exercise care with dissection.

➣ Immobilizationa 45◦ flexion with compression for 7–10 days.

  • If rheumatoid ,consider longer immobilization.
  • Consider drain use in rheumatoid patients,large bursae.
  • Secondary aspiration of dead space occasionall necessary.

Complications of surgical treatment

➣ Wound problems

➣ Infection

➣ Dehiscence

➣ Recurrence approximately 10%

Prognosis

Many resolve spontaneously with local care and padding.

If untreated,  there are few long-term problems with chronic bursitis other than annoyance.

Infection should be aggressively treated.

Overall prognosis is excellent with symptomatic treatment of chronic bursitis and treatment of infection.

Most surgical cases do well.

Caveats and Pearls

In chronic cases, beware of occult infection and consider addition of oral antibiotics early on.

S.aureus is isolated organismin >90%

Beware of alaceration over the bursa in ice hockey players,as infection rate is extremely high; cover with antibiotics.

Careful surgical technique is critical due to poor blood supply of skin.


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