Hand surgeon Steven H. Goldberg, MD explains olecranon bursitis:
Olecranon bursitis is a common problem that causes pain and swelling near the point of the elbow. There are several causes of olecranon bursitis. In some people we never know what causes this problem. In other people it can begin with trauma or injury to the area. Blood can fill the area, inflammation can occur, or infection can cause the problem. Infections can be either sudden or can slowly grow and become very long lasting. Depending on the cause of the bursitis, the treatment may vary considerably and may just include observation or could require surgery to clean the area.
The olecranon is the pointy part of your elbow. The olecranon bursa is one of many bursas in your body. A bursa is a type of tissue below the skin that produces fluid and helps the skin or deeper tissues move across areas where a lot of motion occurs. The olecranon bursa, for example, helps the skin slide over the olecranon as you bend or straighten the elbow. Other areas where there are bursae include the subacromial and subdeltoid (shoulder) bursa, the greater trochanteric (hip) bursa, and the prepatellar (knee) bursa. Bursitis can occur at any of these areas.
Traumatic bursitis and bursitis where we don’t know the cause (called idiopathic bursitis) are often treated similarly. Traumatic bursitis is often caused by a known single event (you hit the point of the elbow) or could be caused by repetitive or sustained pressure over the elbow. This type of bursitis has swelling, sometimes without much tenderness or pain, and has little skin redness or warmth. There should also be no systemic illness such as fever. There is usually near-normal motion of the elbow and minimal problems with function. Treatment may consist of:
- Compression with elastic bandages
- Padded elbow sleeve
- Splint (occasionally)
- Activity modification to restrict repetitive motion or pressure
It is important to identify the cause of the bursitis and to avoid continuing to injure the bursa. It may take many months for the swelling to resolve. Intervention to reduce symptoms may include needle aspiration, pulling out fluid, and/or steroid injection. There is some limited information that shows that pulling out the fluid and steroid injection results in faster reduced swelling than needle aspiration alone. Unfortunately, steroid injections may have more complications (infection, skin atrophy, chronic pain). Thus, needle aspiration, steroid injection or surgery is often not advised in a patient whose primary complaint is swelling without pain or motion loss.
When blood fills the bursa, we call it hemorrhagic bursitis. This type of bursitis may occur from the combination of a minor trauma and medication side effects when the patient takes a medication that affects platelets or coagulation of blood (commonly known as a “blood thinner”). The most common reasons a patient may take a “blood thinner” are a previous myocardial infarction (heart attack), cerebrovascular event (stroke), deep venous thrombosis (DVT), or pulmonary embolus (PE). These medications can make a patient more prone to bleeding without normal clotting. When bleeding occurs, the increase in size of the bursa can be quick. Pressure should be applied to the area for 10-15 minutes to try to stop progressive bleeding and swelling. The patient should notify the health care provider who ordered the blood thinner to ask if temporary reduction of dose or stoppage of medication can be safely done. For severe swelling where skin is very tight or pale, it may be necessary to remove the blood from the bursa. It is never advisable to reduce or stop blood thinners without talking with your prescribing physician.
Inflammatory bursitis can occur when you have crystalline joint inflammation (gout, pseudogout) or autoimmune problems. Inflammatory bursitis may look and feel very similar to infectious bursitis. Therefore, if there is skin redness, warmth, and pain it is often helpful to use a needle to remove fluid to look for crystals and bacteria. If crystals are present and no bacteria are present, either oral steroids or non-steroidal anti-inflammatories can be used. If taking these medications in pill form does not improve symptoms or if the pain is significant, steroid injection into the bursa or surgical removal of the bursa may be needed. If the patient has known autoimmune disease and neither crystals nor infection are identified, treatment of the underlying disease is advised. If these treatments fail to relieve symptoms, steroid injection into bursa, repeated aspiration, or surgical bursa removal may be needed.
Bursitis from infection or acute bacterial septic bursitis typically requires more aggressive treatment. Initially, the bacteria grow confined to the bursa. However, if the bacteria make it out of the bursa, the infection can spread quickly up and down the arm. If the less common symptoms of fever, heart racing, dizziness, or confusion are present suggesting there is systemic illness, prompt evaluation in the emergency room is advised. When the symptoms are more minor and limited to the elbow with redness, swelling, and pain and no other illness is present, treatment can often be managed in the outpatient setting. The time between onset of symptoms and the evaluation with a healthcare provider may determine the treatment course. If an infection is present for an extended period of time, oral antibiotics may not be sufficient for treatment. Initial treatment may be oral antibiotics alone or aspiration of fluid for analysis along with oral antibiotics. Sometimes repeated needle aspiration to remove fluid is helpful to remove organisms, reduce swelling and pain, and try to avoid the need for surgical debridement. If symptoms fail to respond to antibiotics and/or aspiration, it may be necessary to undergo a surgery to clean the area and remove any diseased tissue. If the skin cannot be closed after surgery, it may be necessary to move muscle to cover the area, perform a skin graft or use a skin substitute. Even when the wound can be closed, chronic drainage can occur and the wound may have delayed healing. Sometimes, immobilization of the elbow can reduce skin motion and tension which can help healing.
Chronic infectious bursitis is often caused by bacteria but may be caused by fungus or other unusual organisms. People with this type of bursitis often have other medical problems that make chronic unusual infections more likely. Culture directed antibiotic management and surgical excision are often required for these unusual problems. As this is a chronic process it can often require more than one surgery.
In summary, multiple causes of olecranon bursitis exist. The first goal in establishing a diagnosis is to determine if there is infection. Infection typically requires antibiotics, may require hospitalization and could require surgical intervention. Non-infectious bursitis is more likely to be present for a long period of time and treated with non-surgical measures like compression, padding, ice, and non-steroidal anti-inflammatory medications.
Steven H. Goldberg is Board Certified in Orthopaedic Surgery and is a Fellowship Trained Hand Surgeon with The Subspecialty Certificate in Surgery of the Hand. He has been a member of the American Society for Surgery of the Hand since 2010 and serves on the Physician Coding and Reimbursement and Public Education Committees. He is ASSH Advisor for the CPT Editorial Panel of the American Medical Association. He currently practices as an Associate in the Department of Orthopaedic Surgery, Geisinger Medical Center