Shoulder and Elbow
- Diagnostic Workup
Indications for Surgery
- Surgical Technique
Pearls and Pitfalls of Technique
- Potential Complications
Outcomes/Evidence in the Literature
The human body has 140 bursae which are synovial sacs that allow gliding between tissue layers with minimal friction. Bursae are susceptible to damage by pressure, trauma, infection, and inflammatory conditions. Bursitis is inflammation of the bursa which leads to pain and swelling. The olecranon bursa is the most superficial bursa in the human body, covering the dorsal olecranon extending from the distal triceps insertion to the proximal ulna. Due to its location, the olecranon bursa is frequently affected by bursitis.
Olecranon bursitis can be classified in multiple ways:
Infectious (Septic): Approximately 20% of all bursitis cases are caused by bacterial infections; rarely bursitis is caused by fungi and algae.
Traumatic (Aseptic): This is the most common type of olecranon bursitis and is typically caused by a traumatic insult causing intrabursal bleeding, release of inflammatory mediators, and subsequent swelling.
Inflammatory: There are multiple inflammatory causes of olecranon bursitis including rheumatoid arthritis, gout, systemic lupus erythematosus, pigmented villonodular synovitis (PVNS), and pseudogout.
Olecranon bursitis typically affects men between the ages of 30 and 60 years old. Patients present with complaints of pain, swelling, and inflammation of the bursa overlying the olecranon/proximal ulna. The swelling and pain can last for several hours to several days in acute cases. The patient often reports a history of repeated minor trauma such as resting their elbow on a hard surface, which has led to the colloquial descriptions: “miner’s elbow,” “student's elbow,” or “barfly elbow.” In the case of septic bursitis, the patient will often report a skin lesion that led to a worsening cellulitis that eventually seeded the olecranon bursa. A thorough history is needed to rule out secondary causes of olecranon bursitis which can include rheumatoid arthritis, gout, systemic lupus erythematosus, and pseudogout.
A unilateral distended bursa can be 6-7 cm long by 2.5 cm wide overlying the proximal ulna. Erythema is present in 63-100% of cases of septic bursitis and 25% of aseptic cases. Septic bursitis may have a cellulitic component or minor injury that seeded the bursa. Patients presenting with olecranon bursitis often have a very prominent olecranon or palpable bone spurs. Acute aseptic olecranon bursitis is heralded by a non-tender fluctuant mass over the proximal olecranon in more than 80% of cases. This is in contrast to cases of septic olecranon bursitis in which the affected bursa is warm, erythematous, and very tender to palpation. Elbow range of motion is often limited by the extent of disease and the degree of tenderness associated with bursal inflammation. Severe cases of bursitis can have an associated joint effusion that further restricts range of motion. Systemic signs including fever greater than 38.0°C may be seen in cases of septic olecranon bursitis.
Medical imaging is not routinely required, but should be used if there is concern for foreign body, fracture, other underlying cause, or to identify the presence of an abscess. Plain radiographs of the elbow are used in the setting of concurrent trauma to rule out the presence of fracture, foreign body, or to identify bone spurs. Ultrasound can be used to identify loose bodies, rheumatoid nodules, or tophaceous gout as underlying causes of the bursitis. Magnetic resonance imaging (MRI) can be used to further evaluate in the presence of severe symptomatology and concern for osteomyelitis or abscess.
Additional tests that can be useful in the workup of suspected olecranon bursitis include an assessment of the fluid aspirated from the inflamed bursa. The aspiration is performed using a sterile technique. Using an 18-gauge needle, the bursa is aspirated from its lateral aspect, making sure to tunnel the needle under the triceps fascia before entering the olecranon bursa to help prevent the formation of a sinus tract. As much fluid as possible is aspirated to provide pain relief and also to allow for an adequate specimen for testing.
The aspirated fluid is initially assessed for appearance with cloudy/purulent material present in cases of septic bursitis and a clear or hemorrhagic fluid in aseptic olecranon bursitis. Polarized light analysis is used to identify monosodium urate (gout) and calcium pyrophosphate dihydrate (pseudogout) crystals as underlying causes. A fluid cell count is obtained with a WBC count greater than 3000/mm3 with a greater than 50% polymorphic nuclear cell concentration concerning for infection. A gram stain and fluid culture are also performed – with Staphylococcus aureus/epidermidis as the offending organism in 90% of cases and Streptococcus species in 9% of cases. Additionally, a fluid glucose level less than 50% of the serum glucose level is correlated with an infectious cause.
For cases of aseptic olecranon bursitis, consider tetanus vaccination/booster in all cases involving traumatic open wounds. For inflammatory causes, the underlying condition must be adequately treated to allow for resolution and to prevent recurrence. In most cases of acute traumatic bursitis, activity modification or simply stopping the inciting activity will resolve the condition. Rest, ice, compression, elevation, and protection of the affected elbow (elbow pad) are mainstays of treatment. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for 10-14 days.
The diagnostic aspiration may also be a therapeutic aspiration with care taken to perform the procedure under sterile conditions to avoid seeding the bursa with skin flora. The elbow should be immobilized for 1 week following the aspiration and a compressive dressing should remain in place for 3 days to prevent chronic drainage. Some authors recommend injecting a corticosteroid injection following the aspiration. The use of corticosteroids is controversial and has been shown to have varying results and varying complication rates. We do not routinely use corticosteroid injections in our practice.
In the case of chronic olecranon bursitis, the bursa should be aspirated after 2 weeks if there is no improvement following conservative measures. If no improvement or recurrence is seen after 3 months, then a discussion of surgical management should occur.
For cases of septic bursitis - culturing of the aspirated fluid will help identify the offending organism with most caused by Staphylococcus aureus and other gram positive organisms. Mild to moderate cases can be managed with 10-14 days of oral antibiotics on an outpatient basis with close follow up. Recommended antibiotics include Penicillinase-resistant penicillin (e.g. nafcillin, dicloxacillin) or a first generation cephalosporin (cephalexin). Close follow up is required to ensure that the clinical picture is improving.
Severe cases of olecranon bursitis may require inpatient admission for more intensive management. Patients demonstrating systemic signs of infection, immunocompromised patients, or patients demonstrating advanced symptoms such as tissue necrosis should be considered for inpatient admission. Intravenous (IV) antibiotics (e.g. gentamicin) should be initiated and further assessed when cultures return. A total of 7-10 days of IV antibiotics should be administered and then followed by 14 days of oral antibiotics. If a patient shows no improvement or worsening symptoms while on IV antibiotics surgical intervention should be discussed.
Indications for Surgery
Indications for surgical intervention include failure of non-surgical management; cases of recurrent chronic bursitis not responding to non-surgical management; persistent or worsening cellulitis after 24-28 hours of antibiotic treatment; the presence of skin necrosis, fistula, abscess, or phlegmon; and worsening systemic signs such as fever, tachycardia, low blood pressure, chills, and mental status change.
Irrigation and Open Bursectomy
This procedure is used in cases of severe septic bursitis, severe soft tissue complications, refractory aseptic cases, and chronic/recurrent aseptic cases. This procedure requires standard surgical instruments including a no. 15 scalpel, electrocautery, dissecting scissors, hemostat, Rongeur, and osteotome. General anesthesia is preferred to allow for complete muscle relaxation and timely neurovascular checks post-operatively.
Patients are positioned prone to allow for a fully accessible surgical site; however, special attention must be paid to padding the face, chest, and bony prominences. Alternatively, the patient can be placed in the lateral decubitus position. The arm is draped across a padded horizontal post attached to the table. This position allows for airway access for the anesthesiologist when patients have a high body mass index (BMI) or have concerning pulmonary function.
After the patient has been anesthetized and positioned the surgical site is prepped and draped using standard techniques. The limb is exsanguinated and a tourniquet is inflated. Using a no. 15 scalpel, a 3 cm dorsal longitudinal incision is made over the enlarged olecranon bursa radial to the tip of the olecranon. Any draining sinus or open wounds should be excised in an elliptical fashion. After surgical exposure of the subdermis, the bursa is identified over the olecranon. Using careful dissection, the entire bursa should be identified so that it may be removed in its entirety. Try to avoid removing the bursa in a piecemeal fashion as this can lead to retained bursal components and recurrence.
The tissues are then copiously irrigated with normal saline using a Pulsavac. On inspection, if any bony spurs are identified they can be removed with a Rongeur or osteotome. The tourniquet should be released and meticulous hemostasis is achieved. The skin is closed with 3-0 nylon horizontal mattress sutures and a posterior slab elbow splint is placed.
This procedure is used for refractory, chronic, and recurrent cases of aseptic bursitis. It can also be used in cases of septic bursitis without significant skin compromise. Arthroscopic bursectomy requires a 4.0 mm 30 degree arthroscope, arthroscopic mechanical shaver, and an arthroscopic mechanical burr. General anesthesia is preferred to allow for complete muscle relaxation and timely neurovascular checks post-operatively. Patients can be placed in the prone position to provide a fully accessible surgical site; however, special attention must be paid to padding the face, chest, and bony prominences. Alternatively, the patient can be placed in the lateral decubitus position. The arm is draped across a padded horizontal post attached to the table.
After the patient has been anesthetized, positioned, and has received preoperative antibiotics, the surgical site is prepped and draped using standard techniques. The limb is exsanguinated and a tourniquet is inflated. Landmarks and locations for three arthroscopic portals are identified: posterior central, direct posterolateral, and proximal anterolateral portal. Medial portals are avoided due to the risk of ulnar nerve injury. A no. 11 blade is used to create a posterior central portal located 2-4 cm proximal to the olecranon and halfway between the medial and lateral condyles. A no. 11 blade is used to create a direct posterolateral portal located at the center of a triangle created by the lateral epicondyle, the olecranon, and the radial head. A no. 11 blade is used to create a proximal anterolateral portal located 1-2 cm proximal to the prominence of the lateral epicondyle along the anterior border of the humerus. The arthroscope is passed into the olecranon bursa and an arthroscopic mechanical shaver is used to debride all of the olecranon bursa. This can be judged when there is an increase in illumination through the skin, representing complete removal of the bursa. On inspection, if any bony spurs are identified they can be removed with an arthroscopic mechanical burr.
The portals are closed with 3-0 nylon sutures and a posterior slab elbow splint is placed. Arthroscopic bursectomy has a faster recovery and better cosmesis due to smaller incisions compared to an open bursectomy.
Pearls and Pitfalls of Technique
Meticulous removal of the complete olecranon bursa will minimize the chances of chronic draining sinus and recurrence.
A balance between immobilization to allow for appropriate skin healing and early mobilization to prevent elbow stiffness must be attained.
Avoid using medial incisions/portals to minimize the risk of ulnar nerve injury.
Infection - reported to be as high as 10% of aspirated/injected elbows.
Chronic pain at location of the injection
Chronic draining sinus
Tenuous skin coverage
Cutaneous nerve damage
Persistent drainage if bursa is not completely removed
Ulnar nerve injury due to proximity
The patient is kept non-weight bearing for 1 week while in the post-operative splint to rest the soft tissues and minimize hematoma formation. In the case of septic bursitis, antibiotics should be continued for at least 7 days following the surgical procedure. At the 1 week post-operative follow up appointment, the splint is discontinued and early range of motion, strengthening, and range of motion exercises are initiated. Sutures are removed at 10-14 days from the surgical procedure. The patient may gradually return to full activity by 4 weeks after the procedure.
Outcomes/Evidence in the Literature
Sayegh, ET. "Treatment of olecranon bursitis: a systematic review". Arch Orthop Trauma Surg. 2014.(This article offers a systematic review of 29 studies regarding the treatment of olecranon bursitis. Based on Level IV evidence, they found that non-surgical management is more effective than surgical management and also caused fewer complications. They also found that corticosteroid injection is associated with significant risk of overall complications and skin atrophy without improving the outcomes of aseptic bursitis.)
Baumbach, SF. "Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm". Arch Orthop Trauma Surg. vol. 134. 2014. pp. 359-370.(This article offers a systemic review of 52 studies on the treatment of olecranon bursitis and provides a treatment algorithm based on its findings. This review did not support immediate bursectomy in the treatment of septic bursitis; instead, it recommends differentiation of septic and aseptic bursitis by fluid aspiration.)
Rinkel, WD. "Current Evidence for Effectiveness of Interventions for Cubital Tunnel Syndrome, Radial Tunnel Syndrome, Instability, or Bursitis of the Elbow: A Systematic Review". Clin J Pain. vol. 29. 2013. pp. 1087-1096.(This article provides a systematic review of 7 studies (1 systematic review and 6 RCTs) of four painful disorders of the elbow. This review found limited evidence for the effectiveness of non-surgical or surgical interventions regarding olecranon bursitis. They recommend well designed and executed randomized controlled trials for treatment of this disorder.)
Buono, AD. "Diagnosis and Management of Olecranon Bursitis". The Surgeon. vol. 10. 2012. pp. 297-300.(This review offers a comprehensive review of the current literature on the diagnosis and management of olecranon bursitis.)
Aaron, DL. "Four Common Types of Bursitis: Diagnosis and Management". JAAOS. vol. 19. 2011. pp. 359-367.(This review published by the AAOS presents four common bursitis types including their evaluation, diagnosis, and management.)
Martinez-Taboada, VM. "Cloxacillin-based therapy in severe septic bursitis: retrospective study of 82 cases". Joint Bone Spine. vol. 76. 2009. pp. 665-669.(This article offers a retrospective study of 82 cases of olecranon bursitis treated with cloxacillin. They found that cases of severe septic bursitis without a significant cellulitis component were effectively treated with cloxacillin. Cases of severe septic bursitis with cellulitis were more effectively treated with a combination of cloxacillin and gentamicin.)
Degreef, I. "Complications following resection of the olecranon bursa". ActaOrthop Belg. vol. 72. 2006. pp. 400-403.(This study offers a retrospective review of 37 cases of olecranon bursitis and found wound healing problems in 27% of cases and recurrence in 22% of cases. They offer suggestions with regard to surgical planning given these complications.)
Schulze, J. "Comparative results after endoscopic synovectomy and open bursectomy in chronic bursitis olecrani". Swiss Surg. vol. 6. 2006. pp. 323-327.(This study presents clinical follow up of nine patients who underwent either open bursectomy of arthroscopic bursectomy for chronic olecranon bursitis. They report high patient satisfaction in both groups but found that patients in the arthroscopic group returned to work earlier.)
Smith, DL. "Treatment of nonseptic olecranon bursitis. A controlled, blinded, prospective trial". Arch Intern Med. vol. 149. 1989. pp. 2527-2530.(This randomized controlled trial included 42 patients with non-septic olecranon bursitis to compare intrabursal steroid injection to treatment with a NSAID. They found at 6-month follow-up that the interbursal steroid group was more effective at managing non-septic olecranon bursitis than NSAID alone.)
Smith, DL. "Septic and nonseptic olecranon bursitis. Utility of the surface temperature probe in the early differentiation of septic and nonseptic cases". Arch Intern Med. vol. 149. 1989. pp. 1581-1585.(This study prospectively investigated 46 cases of olecranon bursitis and evaluated the use of measuring bursal skin temperature as a method of differentiating septic and aseptic olecranon bursitis. They found a 2.2°C temperature difference between septic and aseptic bursitis and suggest that this can be used to support suspicion of septic bursitis.)
Olecranon bursitis is characterized by complaints of pain, swelling, and inflammation of the bursa overlying the proximal ulna. A thorough history and physical exam are required for accurate diagnosis and appropriate treatment. If there is any concern for septic bursitis, the bursa should be aspirated and fluid sent for cell count and culture. Non-operative management is the mainstay of treatment for mild to moderate olecranon bursitis. In cases of suspected mild septic bursitis, outpatient oral antibiotics can be prescribed with close follow up. Patients demonstrating severe septic bursitis may require hospital admission for IV antibiotics. If the patient fails to improve on IV antibiotics, they may require urgent surgery. Open or arthroscopic irrigation and bursectomy are available for severe or refractive cases of olecranon bursitis. More randomized controlled trials are needed to better characterize the most efficacious treatments for olecranon bursitis.
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