Olecranon Bursitis

Question 1

What

Answer 1

refers to inflammation and swelling of the bursa over the elbow. The olecranon is the bony lump at the elbow, which is part of the ulna bone.

Bursae are sacs created by synovial membrane filled with a small amount of synovial fluid. They are found at bony prominences (e.g., at the greater trochanter, knee, shoulder and elbow). They act to reduce the friction between the bones and soft tissues during movement.

Bursitis is inflammation of a bursa. This causes thickening of the synovial membrane and increased fluid production, causing swelling. This inflammation can be caused by a number of things:

Friction from repetitive movements or leaning on the elbow
Trauma
Inflammatory conditions (e.g., rheumatoid arthritis or gout)
Infection – referred to as septic bursitis

Olecranon bursitis is sometimes called “student’s elbow”, as students may lean on their elbow for prolonged periods while studying, resulting in friction and mild trauma leading to bursitis. It can also occur with people with occupations that require leaning on the elbow, such as plumbers or drivers.

Question 2

Present

Answer 2

The typical presentation is a young/middle-aged man with an elbow that is:

Swollen
Warm
Tender
Fluctuant (fluid-filled)

It is important to identify where bursitis is caused by infection. Features of infection are:

Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)

An important differential diagnosis is septic arthritis. Consider septic arthritis if there is:

Swelling in the joint (rather than the bursa)
Painful and reduced range of motion in the elbow

Question 3

Aspirate

Answer 3

The NICE clinical knowledge summaries (updated January 2021) recommend aspiration of fluid from the bursa when an infection is suspected. They advise that the appearance can give an indication of the underlying cause:

Pus indicates infection
Straw-coloured fluid indicates infection is less likely
Blood-stained fluid may indicate trauma, infection or inflammatory causes
Milky fluid indicates gout or pseudogout

Aspiration should ideally be performed before starting antibiotics. The fluid is sent to the lab for microscopy and culture. During microscopy, they will examine for crystals (gout and pseudogout) and gram-staining for bacteria.

Question 4

Manage

Answer 4

Management options for olecranon bursitis include:

Rest
Ice
Compression
Analgesia (e.g., paracetamol or NSAIDs)
Protecting the elbow from pressure or trauma
Aspiration of fluid may be used to relieve pressure
Steroid injections may be used in problematic cases where infection has been excluded

When infection is suspected or cannot be excluded, management involves:

Aspiration of the fluid for microscopy and culture
Antibiotics

The NICE CKS recommend flucloxacillin first-line, with clarithromycin as an alternative.

Patients that are systemically unwell (e.g., immunocompromised or have sepsis) need admission to hospital for further management, including:

Bloods (including lactate)
Blood cultures
IV antibiotics
IV fluids