A 35-year-old, previously healthy woman comes to the office for evaluation of left elbow swelling. The patient says the swelling started a week ago. It is associated with a mild ache but otherwise does not bother her. She works as a computer programmer, and for the past month, she has started intense exercises, including biking, sit-ups, push-ups, weight lifting, and running on a treadmill. The patient reports no trauma to the elbow or fever. Temperature is 37 C (98.6 F), blood pressure is 115/76 mm Hg, and pulse is 86/min. On examination, a 4-cm focal area of swelling is noted over the tip of the olecranon that is slightly tender and fluctuant on palpation. There is no warmth, erythema, or evidence of abrasion. Range of motion of the shoulders, elbows, and wrists is normal. The remainder of the examination is normal. Which of the following is the most appropriate next step in management?
Olecranon bursitis | |
Etiology |
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Clinical |
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Evaluation |
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Management |
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NSAIDs = nonsteroidal anti-inflammatory drugs. | |
This patient has olecranon bursitis presenting with localized swelling over the posterior elbow. The olecranon bursa is a fluid-filled synovial sac located between the olecranon process and the skin; it alleviates friction at the bony prominence. Due to its exposed location, repetitive pressure, overuse (eg, due to upper extremity exercise), or other microtrauma can injure the bursa, leading to synovial fluid accumulation.
The rounded golf ball–shaped fluid accumulation in the bursa is commonly apparent on inspection and is fluctuant on palpation. Chronic microtraumatic bursitis is noninflammatory, so erythema, warmth, and significant pain are typically absent. Because the bursa is not intraarticular, bursitis typically does not interfere with range of motion unless it is significantly enlarged or inflamed. Treatment includes activity modification (to decrease elbow friction), ice, nonsteroidal anti-inflammatory drugs, and elbow padding.
Other etiologies of olecranon bursitis include acute trauma (eg, hemorrhagic bursitis), infection (eg, from abrasions or penetrating trauma), and rheumatologic disease (eg, gout, rheumatoid arthritis). The latter two present with redness, warmth, and significant pain, features absent in chronic microtraumatic bursitis. These features necessitate a complete blood count with differential as well as aspiration of bursal fluid (eg, cell count with differential, Gram stain, culture) to rule out infection (Choice A).
(Choice B) Corticosteroid injection is not recommended for chronic microtraumatic olecranon bursitis because it is not effective and has potential adverse effects (eg, iatrogenic septic bursitis, skin atrophy). It is more appropriate for deep bursitis (eg, subacromial) or occasionally for sterile, inflammatory (eg, gout) bursitis.
(Choice C) Elbow joint arthrocentesis is indicated for septic or inflammatory arthritis (eg, rheumatoid arthritis). These patients typically have significant pain and decreased range of motion due to intraarticular effusion and inflammation. In contrast, patients with chronic microtraumatic bursitis have preserved joint movement.
(Choice E) Elbow x-ray to rule out fracture should be considered in patients with acute traumatic bursitis (eg, fall). This patient has no acute trauma or severe tenderness to suggest a fracture.
Educational objective:
Olecranon bursitis presents with localized swelling over the posterior elbow, usually due to repetitive pressure, overuse, or other microtrauma to the bursa. Treatment includes activity modification, nonsteroidal anti-inflammatory drugs, and elbow padding. However, redness, warmth, or significant pain suggests an infectious or inflammatory etiology and warrants bursal fluid aspiration.