What is the diagnosis and treatment for a patient with swelling and tenderness around the elbow, a history of trauma, and possible repetitive elbow movement or direct trauma to the elbow?

Diagnosis and Management of Elbow Bursitis

Clinical Diagnosis

Elbow (olecranon) bursitis is diagnosed clinically based on swelling and tenderness over the posterior elbow, with a history of trauma or repetitive pressure being the most common etiology. 1

Key Diagnostic Features

• Distinguish septic from non-septic bursitis immediately - approximately one-third of olecranon bursitis cases are septic, and this distinction drives all subsequent management decisions 2

• Clinical features suggesting septic bursitis include:

  • Fever or systemic symptoms 3
  • Marked erythema extending beyond the bursa 2
  • Severe tenderness disproportionate to swelling 2
  • Warmth and fluctuance 1

• Both septic and non-septic bursitis can present with local erythema, so clinical features alone are insufficient to rule out infection 2

Mandatory Diagnostic Workup

• Bursal aspiration should be performed in all cases to definitively distinguish septic from non-septic bursitis 2

• Synovial fluid analysis must include:

  • White blood cell count (>3000 cells/mm³ suggests infection) 3
  • Gram stain and culture 2
  • Microscopy for crystals if gout/pseudogout suspected 2

• Plain radiographs of the elbow are appropriate initial imaging to rule out fracture, heterotopic ossification, or olecranon spurs, though they are not required for diagnosis of uncomplicated bursitis 4, 5

Treatment Algorithm

For Septic Olecranon Bursitis (Confirmed by Aspiration)

• Initiate oral antibiotics covering Staphylococcus aureus (the most common causative organism) after aspiration and culture 3, 2

• Repeated aspiration may be necessary if fluid reaccumulates 2

• Hospital admission with parenteral antibiotics is indicated for:

  • Failure to improve with oral antibiotics within 48-72 hours 3
  • Systemic signs of infection 3
  • Immunocompromised patients 1

• Surgical washout is reserved for cases refractory to antibiotics and repeated aspiration 3, 1

• Recovery can take months even with appropriate treatment 2

For Non-Septic Olecranon Bursitis

• Conservative management is first-line and resolves most cases: 1, 6

  • Rest and activity modification (avoid direct pressure on elbow) 1, 6
  • Ice application 1, 6
  • Compression with elastic bandage 1, 6
  • NSAIDs for pain and inflammation 1, 2

• Aspiration alone (without corticosteroid injection) can provide symptomatic relief and hasten resolution 2, 6

• Intrabursal corticosteroid injections produce rapid resolution but should be used cautiously due to concerns about long-term local adverse effects, including skin atrophy and increased infection risk 2, 6

• Surgical bursectomy is reserved for recalcitrant cases that fail conservative management, but recent literature demonstrates adverse effects compared with noninvasive management for initial treatment 1, 6

Critical Pitfalls to Avoid

• Never inject corticosteroids without first ruling out infection - steroid injection into septic bursitis can lead to devastating complications 1, 2

• Do not rely on clinical appearance alone to distinguish septic from non-septic bursitis, as both can present with erythema 2

• Avoid premature surgical intervention - most non-septic cases resolve with conservative management, and surgery has higher complication rates 6

• Ensure adequate antibiotic duration for septic bursitis - short courses lead to treatment failure and recurrence 3, 2