What are the treatment and diagnosis options for olecranon bursitis?

Diagnosis and Treatment of Olecranon Bursitis

The management of olecranon bursitis should begin with proper diagnosis through imaging and aspiration, followed by a stepwise treatment approach starting with conservative measures including NSAIDs, with surgical intervention reserved for refractory or septic cases.

Diagnosis

Clinical Evaluation

• Look for swelling over the posterior elbow (olecranon process)
• Assess for:
  • Local erythema, warmth, and tenderness
  • Fever (>37.8°C suggests septic bursitis)
  • Skin lesions or wounds (suggests infectious etiology)
  • Prebursal temperature difference >2.2°C (suggests infection) 1

Diagnostic Imaging

• Plain radiographs should be the first imaging test to rule out fractures, loose bodies, or other bony abnormalities 2
• Ultrasound is useful for:
  • Confirming bursal fluid collection
  • Evaluating bursal wall thickening
  • Guiding aspiration 2
• MRI may be considered for cases with suspected associated conditions or when diagnosis remains unclear 2

Bursal Aspiration

• Essential for differentiating septic from non-septic bursitis 1, 3
• Analyze aspirate for:
  • Appearance (purulent suggests infection)
  • White blood cell count (>3,000 cells/μL suggests infection)
  • Glucose (fluid-to-serum ratio <50% suggests infection)
  • Gram stain and culture (positive confirms infection) 1

Treatment

Non-Septic Olecranon Bursitis (2/3 of cases)

1. Conservative Management (First-Line)

   • Rest and activity modification to avoid pressure on the elbow 4
   • Ice application for 10-minute periods through a wet towel 2
   • NSAIDs (e.g., naproxen 500mg twice daily) for pain and inflammation 5
   • Compression and elevation (PRICE principle) 1

2. Aspiration

   • Consider for symptomatic relief when conservative measures fail
   • May need to be repeated for recurrent fluid accumulation 1, 3

3. Intrabursal Corticosteroid Injection

   • Consider for patients with high athletic or occupational demands who fail to respond to initial measures
   • Note: Concerns exist about potential long-term local effects 1, 3

Septic Olecranon Bursitis (1/3 of cases)

1. Aspiration and Antibiotics

   • Aspirate bursa to remove purulent fluid
   • Start empiric antibiotics covering Staphylococcus aureus (most common pathogen)
   • Adjust antibiotics based on culture results
   • Continue antibiotics for a prolonged course (typically 10-14 days) 1, 3

2. Repeated Aspiration

   • May be necessary if fluid reaccumulates 3

3. Surgical Intervention

   • Reserved for cases that are:
     • Refractory to conservative treatment
     • Chronically recurrent
     • Severely infected with systemic symptoms 6, 1
   • Options include:
     • Incision and drainage
     • Open bursectomy
     • Arthroscopic bursectomy (increasingly considered as a minimally invasive alternative) 7

Special Considerations

Chronic/Recurrent Cases

• Consider underlying conditions:
  • Crystal deposition diseases (gout)
  • Rheumatologic disorders
  • Biomechanical factors 4

Prevention

• Avoid direct pressure on the elbow
• Consider elbow pads for those with occupational risks
• Strengthening exercises for supporting muscles 4

Prognosis

• Non-septic bursitis typically resolves within 2-3 weeks with conservative treatment
• Septic bursitis may take months for complete recovery 3
• Recurrence is common, especially without addressing underlying causes

Complications

• Chronic bursitis
• Soft tissue defects requiring complex closure procedures in severe cases 8
• Fistula formation
• Wound healing disorders

Remember that approximately one-third of olecranon bursitis cases are septic, making proper diagnosis through aspiration crucial for appropriate management 1, 3.