What is the best treatment approach for a patient with wrist bursitis?

Wrist Bursitis Treatment

For wrist bursitis, initiate conservative management with rest, ice, activity modification, and oral NSAIDs (naproxen 500 mg twice daily), reserving corticosteroid injection for cases that fail to respond after 2-4 weeks of conservative therapy. 1, 2

Initial Conservative Management (First-Line for All Cases)

• Apply ice to the affected wrist for 15-20 minutes, 3-4 times daily to reduce inflammation and pain 1, 3
• Modify activities to avoid repetitive wrist motions and positions that aggravate symptoms, particularly repetitive gripping or prolonged wrist flexion/extension 1, 3
• Prescribe oral NSAIDs as first-line pharmacological treatment: naproxen 500 mg twice daily (maximum 1000 mg/day for chronic conditions) 4, 1, 2
• Elevate the affected extremity when possible to reduce swelling 3
• Apply compression with elastic bandage if significant swelling is present 3

When to Consider Bursal Aspiration

• Perform aspiration only if septic bursitis is suspected (acute onset, fever, warmth, erythema, systemic symptoms) 2
• Send aspirated fluid for Gram stain, culture, cell count, glucose measurement, and crystal analysis to distinguish infectious from inflammatory causes 2
• Do NOT routinely aspirate chronic microtraumatic bursitis due to risk of introducing iatrogenic infection 2

Corticosteroid Injection (Second-Line Treatment)

• Consider intrabursal corticosteroid injection only after 2-4 weeks of failed conservative management in non-infectious cases 2
• Exercise extreme caution with wrist injections: while corticosteroid injections are used for olecranon and prepatellar bursitis, injection near tendons (as in the wrist) may adversely affect biomechanical properties 1
• Ensure infection is completely excluded before any corticosteroid injection, as steroids can worsen septic bursitis 2

Management of Septic Bursitis

• Initiate oral antibiotics effective against Staphylococcus aureus (the most common pathogen) for outpatient management if patient is not acutely ill 2
• Hospitalize and administer IV antibiotics if patient appears acutely ill, has systemic symptoms, or has failed outpatient management 2
• Reserve surgical excision for cases not responsive to antibiotics or recurrent septic bursitis 2

Adjunctive Physical Therapy Modalities

• Prescribe structured rehabilitation exercises including range-of-motion and strengthening exercises once acute inflammation subsides 5, 6
• Consider ultrasound or electrical stimulation as adjunctive treatment modalities to facilitate healing 3
• Initiate passive wrist exercises 3 days post-acute phase, progressing to active exercises after 1 week 6

Surgical Intervention (Last Resort)

• Refer for surgical excision only if conservative management fails after 3-6 months and symptoms significantly impair function 1, 2
• Consider arthroscopic bursectomy over open excision when surgery is indicated, as it reduces wound complications while effectively removing pathological tissue 7

Critical Pitfalls to Avoid

• Never inject corticosteroids without first excluding infection—this can lead to catastrophic worsening of septic bursitis 2
• Do not routinely aspirate chronic microtraumatic wrist bursitis—aspiration increases risk of iatrogenic infection without proven benefit 2
• Avoid prolonged NSAID use without gastroprotection in high-risk patients (age >65, history of GI bleeding, concurrent anticoagulation) 5
• Do not overlook carpal tunnel syndrome as a comorbid condition—chronic wrist bursitis can coexist with median nerve compression requiring separate management 6
• Never continue NSAIDs indefinitely—reassess necessity and efficacy every 4-8 weeks, using the lowest effective dose 5