What is the management approach for olecranon (elbow) bursitis?

Management of Olecranon Bursitis

Nonsurgical management is significantly more effective and safer than surgical management for olecranon bursitis and should be the first-line treatment approach. 1

Diagnosis and Classification

Olecranon bursitis presents as inflammation of the fluid-filled sac (bursa) that cushions the olecranon process of the ulna. It can be classified as:

1. Non-septic (aseptic) bursitis: Caused by trauma, repetitive microtrauma, or inflammatory disorders
2. Septic bursitis: Caused by infection, typically through direct inoculation or adjacent infection spread

Clinical Assessment

• Position the patient with elbow flexed at 90° for proper examination 2
• Radiographs are beneficial as initial imaging to exclude fractures or bony abnormalities 3, 2
• Ultrasound can confirm bursal fluid collection and evaluate bursal wall thickening 2
• Always aspirate if infection is suspected, and send fluid for culture 2

Treatment Algorithm

1. Non-Septic Olecranon Bursitis

First-line (1-2 weeks):

• RICE protocol (Rest, Ice, Compression, Elevation) 2
• NSAIDs (e.g., naproxen 500 mg every 12 hours) 2, 4
• Activity modification to reduce pressure on the affected elbow 2
• Protective padding to prevent recurrence 2

If no improvement after 1-2 weeks:

• Aspiration alone may be sufficient for non-septic cases 2
• Avoid corticosteroid injections as they are associated with increased complications including skin atrophy, infection, and chronic local pain 2, 1

For persistent cases (after 4-6 weeks of conservative treatment):

• Consider surgical referral, though nonsurgical management has been shown to be more effective and safer than surgical intervention 1

2. Septic Olecranon Bursitis

Immediate management:

• Aspiration of bursal fluid for culture and sensitivity 2, 5
• Empiric antibiotic therapy pending culture results 2
  • Coverage for Staphylococcus aureus (most common pathogen) 5
  • Consider coverage for streptococci (second most common) 5

Ongoing management:

• Adjust antibiotics based on culture results 2
• Continue antibiotics for at least 14 days (shorter duration associated with higher failure rates) 5
• May require repeated aspirations 2
• Severe cases may need admission for IV antibiotics 2

Surgical intervention:

• Reserved for cases that fail to respond to medical management 2, 1
• Higher complication rates including persistent drainage and infection compared to nonsurgical management 1

Important Considerations

Complications to Watch For

• Non-septic bursitis has been associated with higher overall complication rates than septic bursitis 1
• Surgical management shows higher rates of overall complications, persistent drainage, and bursal infection than nonsurgical approaches 1
• Corticosteroid injections increase risk of skin atrophy and overall complications 1

Prevention of Recurrence

• Address underlying mechanical factors with protective padding 2
• Correct biomechanical abnormalities 2
• Modify activities that cause repetitive trauma 2
• Treat underlying medical conditions (e.g., gout, rheumatoid arthritis) 2

Expected Outcomes

• Non-septic bursitis typically resolves within 2-3 weeks with conservative treatment 2
• Septic bursitis recovery can take months 2
• Recurrence is common if causative factors are not addressed 2

Key Pitfalls to Avoid

• Using corticosteroid injections as first-line therapy (increases complications) 2, 1
• Premature surgical intervention (associated with higher complication rates) 1
• Inadequate duration of antibiotics for septic bursitis (should be at least 14 days) 5
• Failure to aspirate and culture when infection is suspected 2