Assessment and Plan: Possible Olecranon Bursitis, Right Elbow
Clinical Clarification
The described location "below the elbow on forearm" is anatomically inconsistent with olecranon bursitis, which occurs at the posterior tip of the elbow over the olecranon process. If swelling is truly on the forearm distal to the elbow joint, alternative diagnoses must be considered including soft tissue injury, occult fracture, or infection 1.
Initial Diagnostic Approach
If Swelling is at Posterior Elbow (True Olecranon Bursitis):
Immediately determine if this is septic versus non-septic bursitis, as one-third of olecranon bursitis cases are septic and require fundamentally different management 2.
Clinical features suggesting septic bursitis:
- Fever or systemic symptoms
- Severe erythema extending beyond bursa
- Warmth and tenderness disproportionate to swelling
- History of penetrating trauma or immunocompromise 3, 2
Perform bursal aspiration if infection cannot be clinically excluded 2. Send fluid for:
- Gram stain and culture
- White blood cell count with differential
- Crystal analysis
- Glucose measurement 3
If Swelling is on Forearm (Not Olecranon Bursitis):
Obtain plain radiographs (AP, lateral, oblique views) as the mandatory first imaging study 1. This evaluates for occult fracture or soft tissue gas suggesting necrotizing infection.
If radiographs are normal but fracture suspected: Proceed to CT without contrast 1.
If radiographs are normal but soft tissue injury suspected: Proceed to MRI without contrast to evaluate tendons, ligaments, and bone marrow edema 1.
Initial Treatment
For Non-Septic Olecranon Bursitis (Acute Traumatic):
Conservative management is first-line treatment 4, 3:
- Ice application
- Elevation and rest
- Compression padding
- NSAIDs for analgesia and anti-inflammatory effect 3, 5
Aspiration may shorten symptom duration in acute traumatic/hemorrhagic bursitis 3, 5. However, aspiration of chronic microtraumatic bursitis is generally not recommended due to risk of iatrogenic infection 3.
Avoid intrabursal corticosteroid injection in traumatic olecranon bursitis. While it produces rapid resolution (usually within one week), it carries significant complication rates including infection (12%), skin atrophy (20%), and chronic local pain (28%) 6. Given that spontaneous resolution occurs with conservative treatment, corticosteroids are not justified 6.
For pain management, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as needed 7. Initial daily dose should not exceed 1250 mg, with subsequent days not exceeding 1000 mg daily 7.
For Septic Olecranon Bursitis:
Initiate antibiotics effective against Staphylococcus aureus immediately 3.
Outpatient oral antibiotics may be considered if patient is not acutely ill; hospitalize for IV antibiotics if systemically ill 3.
Perform aspiration for decompression; repeat aspiration may be necessary 5, 2.
Recovery from septic bursitis can take months, and some cases require surgical drainage if unresponsive to antibiotics 3, 2.
Common Pitfalls
Do not assume all erythema indicates infection—both septic and non-septic bursitis can present with local erythema 2. Aspiration with fluid analysis is the definitive method to distinguish them.
Do not use corticosteroid injections for acute traumatic bursitis despite their rapid effect—the complication rate is unacceptably high 6.
Do not repeatedly aspirate chronic non-septic bursitis—this increases infection risk without proven benefit 3.