Management of Olecranon Bursitis in a Construction Worker
For a construction worker with olecranon bursitis persisting for 3 weeks with pain on pressure, aspiration should be performed to differentiate septic from aseptic bursitis, as this distinction fundamentally determines treatment and one-third of cases are septic. 1
Initial Diagnostic Approach
Aspiration is mandatory in all cases of olecranon bursitis to guide appropriate management, as clinical features alone cannot reliably distinguish septic from aseptic causes despite local erythema potentially appearing in both. 1 The aspirated fluid should undergo:
- Cell count and differential (septic bursitis typically shows >1000 cells/mm³) 2
- Gram stain and culture (aerobic and anaerobic) to identify organisms 1
- Crystal analysis if rheumatological causes are suspected 1
The occupational history is particularly relevant here—construction work involves sustained pressure on elbows, which is a well-documented risk factor for both septic and aseptic olecranon bursitis. 2 Seventeen of 25 patients in one series had occupations requiring sustained pressure on elbows or knees. 2
Management Based on Aspiration Results
If Septic Bursitis is Confirmed
Septic olecranon bursitis requires repeated aspiration combined with prolonged antibiotic therapy. 1 The evidence shows:
- Staphylococcus aureus is identified in 88% of cases (22 of 25), with 76% resistant to penicillin 2
- Intravenous antibiotics with bursal drainage were uniformly successful in the original series 2
- Oral antibiotics can be successful unless infection is extensive or underlying bursal disease exists 2
- Treatment duration is prolonged—recovery can take months even with appropriate therapy 1
The IDSA guidelines emphasize that the term "cellulitis" should not be used for inflammation surrounding a suppurative focus like infected bursa; the correct terminology is "septic bursitis with surrounding inflammation," and the primary treatment is drainage of pus, not just antibiotics. 3
If Aseptic (Non-Septic) Bursitis is Confirmed
Non-septic olecranon bursitis can be managed with aspiration alone, which may provide both diagnostic and therapeutic benefit. 1 Additional conservative measures include:
- Rest and activity modification—critical for a construction worker who must avoid repetitive elbow pressure 4, 5
- NSAIDs to hasten symptomatic improvement 1
- Ice application in the acute phase 5
Intrabursal corticosteroids produce rapid resolution but concern remains over long-term local effects, so they should be used judiciously. 1
When Conservative Management Fails
For cases unresponsive to conservative treatment after appropriate trial:
- Repeated aspiration may be necessary 1
- Arthroscopic bursectomy is increasingly considered as it avoids wound complications common with open excision 5
- Hydrothermal ablation at 50-52°C showed 75% success rate with 91.9% volume reduction and significantly fewer complications than open bursectomy in a 2024 study 6
Critical Pitfalls to Avoid
Septic bursitis was misdiagnosed as non-septic in 8 of 25 cases (32%) despite characteristic bursal fluid leukocytosis and positive cultures, leading to delayed appropriate treatment. 2 This underscores why aspiration with laboratory analysis is non-negotiable.
Do not assume aseptic bursitis based on chronicity alone—the 3-week duration does not exclude infection, and trauma (common in construction work) can cause both septic and non-septic bursitis. 1
Occupational Considerations
Early recognition and preventive measures are necessary to reduce morbidity, particularly in occupational settings. 2 For this construction worker, return to work modifications should include: