The olecranon bursa is a thin fluid-filled sac on the tip of the elbow (olecranon) that allows the skin to glide over the olecranon without friction. Bursitis implies inflammation of the bursa. This can be septic (infective) or non-infective bursitis. Patients with diabetes, rheumatoid arthritis, gout, psoriasis, alcoholism and immune suppression have an increased risk of developing olecranon bursitis. Septic olecranon bursitis is most common in middle-aged men, often manual labourers, with a preceding injury to the tip of the elbow. Bacteria can enter the olecranon bursa when the overlying skin is breached.
Swelling develops over the tip of the elbow, and can often be as big as a golf ball (see image). It can develop fairly quickly after a direct blow to the tip of elbow or it can develop gradually after repetitive pressure on the tip of elbow. Non-infective olecranon bursitis is usually not very painful and elbow movement will be normal. Subcutaneous nodules (tophi) may be palpable in addition to the olecranon swelling in patients with gout. Septic olecranon bursitis will normally present with additional redness and warmth over the tip of the elbow and it is usually very painful during elbow movement. Patients can also develop fever when the olecranon bursitis is septic.
When olecranon bursitis develops without a preceding injury, the diagnosis is usually made on clinical grounds alone. If there was trauma to the elbow, an x-ray may be required to rule out an underlying fracture or foreign body. The fluid in the bursa can be aspirated with a needle and syringe to determine if it is septic (infective) or non-infective bursitis. Certain blood investigations can additionally be performed to confirm an infection.
Most patients with non-infective olecranon bursitis can be managed without surgery. Treatment consist of:
- Anti-inflammatory medication and simple pain killers
- Ice packs are helpful in the acutely painful period
- Padding: place a soft pad under the elbow when the elbow is placed on an arm rest or desk.
- Aspiration: The bursitis is often aspirated when the diagnosis is made, but the effect is usually temporary and the fluid will re-accumulate in the bursa over time.
- Steroid injections: Following needle aspiration, a cortisone injection may be given into the bursa to alleviate the inflammation. This carries a risk of introducing infection into the bursa and causing septic olecranon bursitis which is much worse than non-infective olecranon bursitis.
Surgical management of non-infective olecranon bursitis
Surgical removal of the olecranon bursa can be considered in patients with longstanding olecranon bursitis that failed to respond to conservative management. The operation can be performed under a general anaesthetic (the patient is asleep) or under regional anaesthesia (patient is awake, but the arm is blocked with an injection). Tissue samples are sent to the laboratory to exclude an infection and to look for crystals (present in gout). Surgical removal carries a risk of wound complications, seeing that the overlying skin is so thin. Therefore, we only consider surgery when all other methods have failed.
Surgical management of septic olecranon bursitis
The most reliable way of treating septic (infective) olecranon bursitis is with surgical drainage of the pus collection and removal of the infected bursa. The operation can be performed under a general anaesthetic (the patient is asleep) or under regional anaesthesia (patient is awake, but the arm is blocked with an injection). Tissue samples are sent to the lab to identify the causative organism. A drain is usually left inside the bursa for 24-48 hours to allow any further fluid/pus to drain. The elbow will be splinted after surgery. Patients will often require a second clean-out in theatre 48-72 hours later. Antibiotics will be given through a drip for a few days and then in tablet form for 2-3 weeks. The splint will be removed at 2 weeks when the sutures are removed.
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