A 16-year-old male came to clinic as 5 hours earlier while in school he noted that his right elbow was swollen. He watched it for about an hour and thought that it was enlarging so he saw the school nurse. The nurse was concerned and called his parents who took him to a local urgent care center. Over that time, the elbow continued to swell. The family was not happy with the care provided at the urgent care center so they brought him to the pediatric clinic. He denied any trauma, pain or decreased motion. He denied any recent insect bites, minor scratches or pruritis. The past medical history showed a healthy male. The review of systems was negative for fever, rash, sore throat, cough, upper respiratory tract infection symptoms, genitourinary symptoms, emesis, diarrhea, nausea or headache.
The pertinent physical exam showed a healthy male with normal vital signs and he was afebrile. His elbow was markedly swollen posteriorly with no external landmarks visible. There was a 5 cm difference in size greater than the left. He had swelling that was located 2-3 cm above the palpated olecranon process and 5 cm below it. The swelling had increased from those marked by the school nurse (2 cm distally and 1 cm proximally) and the urgent care center (1 cm distally and 1/2 cm proximally). There was a faint pink area of 2 cm centered over the olecranon process. He had full range of motion without pain in the entire extremity. Pulses were normal. The patient complained of some tingling over the swollen area. There was no discernable temperature difference between the affected and unaffected areas. Palpation of the boney areas and also the muscle groups themselves did not produce pain. His skin examination showed mild acne of the face and back, but none on the arms and a detailed examination of the arm was negative for any skin changes.
The diagnosis of olecranon bursitis that was septic or aseptic, developing cellulitis or much less likely septic arthritis were considered. Fracture, tendonitis or ligamentous injuries appeared remote because of no history of trauma and no pain. The radiologic evaluation of plain radiographs were normal. His laboratory evaluation included a normal complete blood count with a white blood cell count of 3.6 x 1000/mm2 and no left shift. His erythrocyte sedimentation rate was 2 mm/hr and C-reactive protein was < 0.5 mg/dl. The patient’s clinical course while in the clinic showed that he continued to have increased spreading of the swelling and also more developing erythema of the area directly over the olecranon process. He also said that he was now having a little bit of pain in the general area. An orthopaedist was consulted because of the concern for developing septic bursitis vs cellulitis who saw the patient within the hour. Examination at that time showed no continued progression of the general area of swelling or the smaller area of erythema. The patient also denied any pain at that time. The orthopaedist felt that this was aseptic olecranon bursitis and the patient was to use a protective brace, non-steroidal anti-inflammatory medication and to monitor for any significant changes. Over the next several days the swelling began to resolve.
Bursa are the body’s bumper pads for tendons. They are a small synovial fluid-filled sac that lies between tendon and a bone or skin. There are more than 150 of them in the body. With bursitis there can be thickening and proliferation of the synovial lining, bursal adhesions, chalky deposits and villus formation. Trauma, repetitive stress, infection and autoimmune usually are the reasons for bursitis but idiopathic etiology also occurs. The differential diagnosis includes infection, arthritis, tendonitis, tendon or ligament injury, fracture or neoplasm. The usual signs and symptoms are localized pain and tenderness over a bursa, and if the bursa is superficial edema can be seen. Other specific signs and symptoms occur because of location. Bursitis is described as septic or aseptic and acute vs. chronic. Recurrence is common in certain locations such as the olecranon.
Olecranon bursitis (OB) is sometimes called “student’s elbow” or “miner’s elbow” because of the association with these occupations and the obvious repetitive stress to the elbow that can occur. The incidence is not known but it is more common in males aged 30-60 years. Septic OB is more often caused by common skin pathogens of Staphylococcus aureus and Staphylococcus epidermidis (90%) and Streptococcus (9%). Aseptic OB is caused by idiopathic, trauma or crystal-inducing disease processes such as gout.
The olecranon bursa forms after age 7. It is superficial and covers the dorsal olecranon extending from the distal triceps insertion to the proximal subcutaneous ulnar border. If acutely distended this bursa can be 6-7 cm long and 2.5 cm wide.
OB has a unilateral posterior swelling over the olecranon process which may be painless or painful and symptoms are quite variable. Septic OB is less common (only 20% of cases) and usually has more pain and tenderness than aseptic bursitis but both can have cellulitic components and be indistinguishable. For example, erythema is seen in 63-100% of septic OB and 25% of aseptic OB. Pain also does not distinguish between septic and aseptic OB. Septic arthritis of the elbow is usually distinguished from OB because of increased pain with flexion. The flexion decreases the joint space and therefore increases the pain because the joint space fluid is under increased pressure during flexion.
Evaluation may include radiographs (plain or magnetic resonance imaging), metabolic evaluation and possibly aseptic aspiration of the bursa. Treatment is most commonly conservative with joint protection to decrease trauma, non-steroidal anti-inflammatory drugs, and occasional aspiration for drainage. Unfortunately joints that are aspirated often have recurrence. Septic bursitis is treated with anti-bacterial drugs for the common pathogens. For chronic OB, conservative treatment is offered, but additional corticosteroid injections or various surgical procedures are sometimes undertaken.
Questions for Further Discussion
1. How does prepatellar bursitis present?
2. How does retrocalcaneal bursitis present?
- Specialty: Orthopaedic Surgery and Sports Medicine
- Age: Teenager
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Stewart NJ, Manzanares JB, Morrey BF. Surgical treatment of aseptic olecranon bursitis. J Shoulder Elbow Surg. 1997 Jan-Feb;6(1):49-54.
Aaron DL, Patel A, Kayiaros S, Calfee R.
Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011 Jun;19(6):359-67.
Del Buono A, Franceschi F, Palumbo A, Denaro V, Maffulli N. Diagnosis and management of olecranon bursitis. Surgeon. 2012 Oct;10(5):297-300.
Maffulli A, Longo UG, Denaro V. Bursitis. ePocrates.
Available from the Internet at https://online.epocrates.com/noFrame/showPage?method=diseases&MonographId=523&ActiveSectionId=52 (rev. 4/24/14, cited 10/3/14).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital