What is the next step in managing olecranon (elbow) bursitis?

Management of Olecranon Bursitis

The next step in managing olecranon bursitis is to determine whether the bursitis is septic or non-septic through bursal aspiration with fluid analysis (Gram stain, culture, cell count), as this distinction fundamentally determines treatment—septic cases require antibiotics with possible repeated aspirations, while non-septic cases can be managed conservatively with rest, ice, NSAIDs, and compression. 1, 2

Initial Assessment and Diagnostic Approach

Clinical Evaluation to Differentiate Septic from Non-Septic

The critical first decision point is distinguishing septic from non-septic olecranon bursitis, as clinical features alone are insufficient 1:

• Aspiration should be performed in all cases to obtain bursal fluid for analysis 1
• Look for fever, extensive cellulitis, and systemic signs suggesting infection 2
• Note that local erythema can occur in both septic and non-septic bursitis, making it an unreliable distinguishing feature 1
• Trauma can cause both septic and non-septic presentations 1

Bursal Fluid Analysis

When infection status remains uncertain after clinical assessment 1:

• Send aspirate for microscopy, Gram staining, and culture 1
• Approximately 67-73% of septic cases will have positive cultures, predominantly staphylococci (73.4%) and streptococci (19%) 2
• Be aware that 19% of bursal samples may remain sterile despite clinical infection 2

Management Based on Diagnosis

Non-Septic Olecranon Bursitis (Conservative Management)

For non-septic cases, conservative therapy is the first-line treatment 3, 4:

• Rest and activity modification 3
• Ice application 3
• NSAIDs for analgesia and anti-inflammatory effect, which likely hasten symptomatic improvement 1
• Compression and padding to prevent re-accumulation 4
• Aspiration alone can be sufficient for chronic non-septic cases 4, 1

Important Caveat About Corticosteroid Injection

While intrabursal corticosteroids produce rapid resolution (often within one week), significant concerns exist about complications 5:

• Infection risk (occurred in 3/25 patients in one study) 5
• Skin atrophy (5/25 patients) 5
• Chronic local pain (7/25 patients) 5
• Given that spontaneous resolution can be expected with conservative management, a conservative approach without corticosteroids is suggested 5

Septic Olecranon Bursitis (Aggressive Management)

Septic bursitis requires aggressive treatment to prevent septicemia 4:

• Aspiration with possible repeated aspirations as needed for decompression 4, 1, 2
• Antibiotic therapy targeting staphylococci as the most common pathogen 2
• IV antibiotics initially if fever or extensive cellulitis present 2
• Antibiotic duration of at least 14 days to minimize failure risk (failure rates higher with <14 days in both medical and surgical groups) 2
• Recovery can take months even with appropriate treatment 1

Surgical Intervention

Surgery is reserved for recalcitrant cases that fail conservative or medical management 3, 4:

• Incision and drainage rarely needed but may be indicated for non-responsive infections 4
• Surgical excision (open or arthroscopic) recommended only for chronic, recurrent cases 3, 4
• Arthroscopic bursectomy increasingly considered as it avoids wound complications common with open excision 3
• Approximately 26% of patients in one series required surgical treatment 2

Common Pitfalls to Avoid

• Do not rely on clinical features alone to distinguish septic from non-septic bursitis—always aspirate 1
• Avoid routine corticosteroid injection in traumatic olecranon bursitis due to complication risks 5
• Do not treat for <14 days with antibiotics in septic cases, as this increases failure rates 2
• Do not rush to surgery—the success rate is equivalent between medical and surgical management when appropriate antibiotic duration is used 2