What is the management of olecranon bursitis?

Management of Olecranon Bursitis

The management of olecranon bursitis should follow a stepwise approach, with conservative treatment as first-line therapy including rest, ice, NSAIDs, and aspiration in specific cases, while reserving surgical intervention for refractory or complicated cases. 1, 2

Diagnosis and Classification

Clinical Assessment

• Evaluate for:
  • Swelling over the olecranon process
  • Pain with direct pressure or elbow movement
  • Erythema (may be present in both septic and non-septic cases)
  • Warmth
  • History of trauma, repetitive pressure, or infection

Classification

1. Non-septic (aseptic) bursitis:

   • Often due to trauma, repetitive pressure, or inflammatory conditions
   • May present with swelling and mild erythema

2. Septic bursitis:

   • Caused by bacterial infection (commonly Staphylococcus aureus)
   • Presents with more pronounced erythema, warmth, and tenderness
   • May have systemic symptoms (fever)

Management Algorithm

1. Non-septic Olecranon Bursitis

First-line Treatment:

• Rest and activity modification
• Ice application (20 minutes several times daily)
• Compression wrap
• NSAIDs (e.g., naproxen 500 mg twice daily) 3
• Avoidance of direct pressure on the elbow
• Protective padding if needed

If No Improvement After 2-3 Weeks:

• Consider aspiration if significant swelling causes discomfort or limits function
• Ultrasound guidance may be helpful 1
• Continue conservative measures

Refractory Cases (No Improvement After 6-8 Weeks):

• Consider referral to specialist
• Options include:
  • Repeated aspiration
  • Surgical intervention (bursectomy) for chronic cases

2. Septic Olecranon Bursitis

Initial Management:

• Aspiration of bursal fluid for diagnosis 4
  • Send for Gram stain, culture, cell count, crystal analysis
  • Cloudy fluid with >3000 WBC/mm³ suggests infection

Treatment:

• Empiric antibiotics covering Staphylococcus aureus 5
  • First-generation cephalosporin or anti-staphylococcal penicillin
  • Adjust based on culture results
• Continue antibiotics for 10-14 days
• Serial aspirations may be needed to remove accumulated fluid
• Rest, elevation, and ice

For Complicated Septic Bursitis:

• Hospitalization for:
  • Systemic symptoms (fever, chills)
  • Immunocompromised patients
  • Failed outpatient treatment
  • Intravenous antibiotics

Surgical Indications:

• Failure of conservative treatment
• Recurrent septic bursitis
• Bursal fistula formation
• Extensive cellulitis
• Necrotic tissue

Special Considerations

Aspiration Technique

• Sterile preparation
• Approach from lateral aspect to avoid the ulnar nerve
• Consider ultrasound guidance for difficult cases 1

Surgical Options

• Open bursectomy: Complete removal of the bursal sac
• Arthroscopic bursectomy: Less invasive option with potentially fewer wound complications 2

Cautions

1. Avoid corticosteroid injections in suspected septic bursitis as they may worsen infection
2. Differentiate from other conditions:
   • Gout
   • Rheumatoid arthritis
   • Olecranon fracture
   • Triceps tendinitis

Follow-up

• Non-septic cases: Review in 2-4 weeks if not improving
• Septic cases: More frequent follow-up (3-5 days) to assess response to antibiotics and need for repeated aspiration
• Recovery from septic bursitis may take months 4

Prevention

• Protective padding for those with occupational risk
• Avoidance of direct pressure on the elbow
• Early treatment of minor trauma or inflammation

The evidence suggests that empirical management without aspiration may be effective for uncomplicated septic olecranon bursitis, with fewer patients requiring surgical bursectomy compared to traditional bursal aspiration 5. However, aspiration remains important for diagnostic purposes when infection is suspected.