October 6, 2019
Treatment algorithm for olecranon bursitis

Treatment Algorithm for Olecranon Bursitis

The dorsal 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.

Definition & Pathophysiology

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).
Elbow XR Olecranon enthesophyte, olecranon bursitis
Image 1: Radiograph of elbow demonstrating small olecranon enthesophyte and bursitis
Elbow US Olecranon bursitis
Image 2: Olecranon bursitis as seen by ultrasound.
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).

Image 1: Example of Compression Sleeve

Treatment

The treatment of aspetic olecranon bursitis is conservative. Further treatment decisions are dictated by etiology of the bursitis (Daniel Aaron, 2011). First line therapy in traumatic cases typically includes non-steroidal anti inflammatories and the wearing of an elbow pad (Eli Sayegh, 2014; Daniel Aaron, 2011).
A study in Clinical Orthopaedics and Related Research looked at patients with nonseptic olecranon bursitis and compared multiple nonsurgical treatment modalities (Joon Yub Kim, 776-783). They randomized patients with nonseptic olecranon bursitis to three groups, with one receiving NSAIDs and compression bandaging, one who had aspiration alone, and one who had aspiration with steroid injection (Joon Yub Kim, 776-783). What they found was that there was no difference in efficacy of resolving the bursitis in the three treatment groups (Joon Yub Kim, 776-783). The only statistically significant finding was that the group who was aspirated and received a corticosteroid injection had quicker time to recovery (Joon Yub Kim, 776-783). Physicians can also consider repeat aspiration if a patient were to have a recurrent effusion (Sebastian F Baumbach, 2014).
However, there has been concern that infection with a corticosteroid can cause adverse side effects. In 1984, a study published in the Annals of Rheumatic diseases looked at patients with olecranon bursitis who received a corticosteroid injection verse those who did not (Philip Weinstein, 1984). What they found was that the group that received a corticosteroid injection had higher rates of skin atrophy and pain (Philip Weinstein, 1984). Another study published in the Scandanavian Journal of Infectious Diseases found that 11% of the patients in their cohort who had received a local corticosteroid injection for nonseptic olecranon bursitis subsequently developed a septic bursa (Soderquist & Hedstrom, 1986). However, in contrast to the data presented by Soderquist and Weinstein, a study published in the Archives of Internal Medicine found that using a lateral approach for aspiration led to their study participants having no episodes of septic bursitis (David Smith, 1989).
The typical first line treatment for septic bursitis is aspiration followed by antibiotics. Due to the prevalence of community acquired MRSA, providers should ensure first line antibiotics have MRSA coverage like Clindamycin and TMP-SMX (Ohl, 2020). In immunosuppressed patients, IV antibiotics should be considered (Ohl, 2020).
When patients fail antibiotic therapy, a referral to an Orthopedic Surgeon may become appropriate. However, olecranon bursectomy is associated with pour wound healing (Danielle Reilly, 2016).

Conclusion

Olecranon bursa effusions are a common finding in an Orthopedic practice. Providers should use caution and weigh the pros and cons of performing an aspiration and administering corticosteroid injections. Future studies should look at the role of ultrasound guided olecranon bursa aspiration and the rates of developing a sinus tract.

Bibliography

1. Bernard F. Morrey, M. M. (2018). Bursitis. In J. S. Bernard Morrey, Morrey’s The Elbow and Its Disorders, Fifth Edition (pp. 705-712). Philadelphia: Elsevier.
2. Daniel Aaron, A. P. (2011). Four Common Types of Bursitis: Diagnosis and Management. Journal of the American College of Orthopedic Surgery, 359-367.
3. Danielle Reilly, S. K. (2016). Olecranon Bursitis. Journal of Shoulder and Elbow Surgery, 158-167.
4. David Smith, J. M. (1989). Treatment of Nonseptic Olecranon Bursitis. Archives of Internal Medicine, 2527-2530.
5. Eli Sayegh, R. S. (2014). Treatment of olecranon bursitis: a systematic review. Archives of Orthopedic and Trauma Surgery, 1517-1536.
6. Elliott, J. (2012). Olecranon Bursitis. In I. T. David Stanley, Operative Elbow Surgery (pp. 547-554). Elsevier.
7. Frank Floemer, W. M. (2004). MRI characteristics of olecranon bursitis. American Journal of Roentgenology, 29-34.
8. Joon Yub Kim, S. W. (776-783). A Randomized Trial Among Compression Plus Nonsteroidal Antiinflammatory Drugs, Aspiration, and Aspiration With Steroid Injection for Nonseptic Olecranon Bursitis. Clinical Orthopaedics and Related Research, 2016.
9. Ohl, C. (2020). Infectious Arthritis of Native Joints. In R. D. John E. Bennett MD, Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (pp. 1400-1417). Elsevier: Philadelphia.
10. Philip Weinstein, J. C. (1984). Long-term follow up of corticosteroid injection for traumatic olecranon bursitis. Annals of the Rheumatic Diseases, 44-46.
11. Sebastian F Baumbach, C. M.-G. (2014). Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Archives of Orthopaedic and Trauma Surgery, 359-70.
12. Soderquist, B., & Hedstrom, S. (1986). Predisposing Factors, Bacteriology and Antibiotic Therapy in 35 Cases of Septic Bursitis. Scandinavian Journal of Infectious Diseases, 305-311.