Workup for Olecranon (Elbow) Bursitis
The workup for olecranon bursitis should begin with plain radiographs of the elbow to exclude fractures, loose bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, or osteoarthritis, followed by bursal aspiration in all cases to differentiate septic from non-septic bursitis through fluid analysis including cell count, Gram stain, and culture. 1, 2, 3, 4
Initial Clinical Assessment
The clinical evaluation must focus on distinguishing septic from non-septic bursitis, as this fundamentally changes management:
History details to obtain: Mechanism of injury (trauma can cause both septic and non-septic bursitis), duration of symptoms, presence of fever or systemic symptoms, occupational factors (repetitive pressure on elbow), and immunocompromised status 4, 5
Physical examination findings: Local erythema can occur in both septic and non-septic bursitis, making clinical features alone insufficient for diagnosis 4. Assess for warmth, fluctuance, tenderness, and range of motion limitations 5
Red flag symptoms: Fever, rapidly expanding swelling, severe pain, or signs of systemic infection warrant urgent evaluation 5
Imaging Studies
Plain radiographs are the mandatory first imaging study:
Anteroposterior and lateral views of the elbow should be obtained to exclude fractures, dislocations, heterotopic ossification, osteochondral lesions, soft tissue calcification, or underlying osteoarthritis 1, 2, 3
Radiographs are often normal in isolated bursitis but are essential to exclude other pathology 2
Visible joint effusion on radiographs may suggest an occult fracture requiring further investigation 3
Comparison with the contralateral elbow can identify subtle asymmetries 3
Ultrasound has a secondary role:
Can visualize bursal fluid and measure bursal volume (useful for monitoring treatment response) 6
May help guide aspiration procedures 7
Can detect nerve thickening if neurological symptoms are present 3
MRI is not routinely indicated but may be considered if radiographs are normal and soft tissue pathology beyond simple bursitis is suspected 3
Bursal Aspiration - The Critical Diagnostic Step
Aspiration should be performed in all cases of olecranon bursitis to definitively distinguish septic from non-septic causes 4:
Fluid analysis must include:
Clinical features are helpful but insufficient alone - approximately one-third of olecranon bursitis cases are septic, and local erythema can occur in both types 4
If infection status remains unclear after initial assessment, microscopy, Gram staining, and culture will resolve the diagnostic uncertainty 4
Common Pitfalls to Avoid
Never assume non-septic bursitis based on clinical appearance alone - trauma can cause both septic and non-septic bursitis, and erythema occurs in both 4
Do not skip radiographs - what appears to be simple bursitis may have underlying fracture, loose body, or other pathology requiring different management 1, 2, 3
Avoid corticosteroid injection before excluding infection - injecting steroids into septic bursitis can lead to devastating complications 4, 8
Recognize that bursal fluid cultures can be positive even without obvious clinical signs of septic bursitis - in one study, only 1 of 24 cases had positive cultures despite none having clinical signs of septic bursitis 6
Rheumatological Causes
While most cases are either septic or non-septic traumatic bursitis, occasional rheumatological causes exist 4:
- Consider crystal arthropathy (gout, pseudogout) if patient has appropriate risk factors
- Rheumatoid arthritis can cause olecranon bursitis
- These diagnoses are made through crystal analysis of aspirated fluid and clinical correlation 5