Olecranon bursitis is a swelling of the subcutaneous, synovium-lined sac that overlies the olecranon process. The bursa functions to cushion the tip of the olecranon and to reduce friction between the olecranon and the overlying skin during elbow motion. Because of the paucity of soft tissue covering the elbow, the olecranon bursa is susceptible to injury.

The causes of olecranon bursitis can be classified as traumatic, inflammatory, septic, and idiopathic [1]. Traumatic bursitis may result from a single, direct blow to the elbow or from repetitive stress. Football players, particularly those who play on artificial turf, are at risk for development of acute bursitis. More commonly, repeated minor trauma from direct pressure on the elbow or elbow motion is responsible for the problem. Trauma is thought to stimulate increased vascularity, resulting in bursal fluid production and fibrin coating of the bursal wall [2]. Persons engaged in certain occupations or certain activities are susceptible to olecranon bursitis, including auto mechanics, gardeners, plumbers, carpet layers, students, gymnasts, wrestlers, and dart throwers. Interestingly, approximately 7% of hemodialysis patients develop olecranon bursitis [3]. Repeated, prolonged positioning of the elbow and anticoagulation appear to be contributing factors.

Inflammatory causes include diseases that affect the bursa primarily, such as rheumatoid arthritis, gout, and chondrocalcinosis. Olecranon bursitis is commonly seen in rheumatoid patients, in whom the bursa may actually communicate with the affected elbow joint. Crystal-induced olecranon bursitis may be difficult to differentiate from septic bursitis.

Septic olecranon bursitis represents 20% of olecranon bursitis [4]. The source is most often transcutaneous, and about half have identifiable breaks in the skin. When culture samples are positive, the bursal fluid usually contains Staphylococcus aureus [5]. Sepsis is unusual. Both underlying bursal disease (gout, rheumatoid arthritis, chondrocalcinosis) and systemic conditions such as diabetes mellitus, uremia, alcoholism, injection drug use, and steroid therapy are considered predisposing factors. There appears to be a seasonal trend, with a peak of staphylococcal septic bursitis during the summer months [6].

In approximately 25% of cases, no identifiable cause of the olecranon bursitis is found. Presumably, repetitive, minor irritation is responsible for the bursal swelling.

Symptoms

Painless swelling is the chief complaint in noninflammatory, aseptic olecranon bursitis. When patients are symptomatic, they usually have discomfort when the elbow is flexed beyond 90 degrees and have trouble resting on the elbow. Moderate to severe pain is the predominant complaint of patients with septic or crystal-induced olecranon bursitis. These patients may also have fever, malaise, and limited elbow motion.

Physical Examination

The physical examination varies somewhat, depending on the underlying condition. With noninflammatory aseptic bursitis, a nontender fluctuant mass is present over the tip of the elbow (Fig. 25.1). Elbow motion is usually full and painless. With chronic bursitis, the fluctuance may be replaced with a thickened bursa (Fig. 25.2).

f25-01-9781455775774 — FIGURE 25.1 Atraumatic olecranon bursitis in a 55-year-old woman. A large, fluctuant mass is present.

f25-02-9781455775774 — FIGURE 25.2 Chronic gouty olecranon bursitis. The prominence at the tip of the elbow is firm with thinning of the overlying skin.

The distinction between crystal-induced and septic bursitis may be subtle. Both conditions may produce tender fluctuance, induration, swelling, warmth, and local erythema. Elbow flexion may be somewhat limited, although not as limited as with septic arthritis of the elbow joint. Fever and a break in the skin over the elbow are important clues to an underlying septic process (Fig. 25.3). Cellulitis extending distally along the forearm is also more likely to be due to an infection.

f25-03-9781455775774 — FIGURE 25.3 Septic olecranon bursitis. Cellulitis is present over a wide area. The white scab at the tip of the elbow represents the site of the penetrating injury. Distally, the draining area of granulation tissue developed at the site of needle aspiration. Aspiration of the bursa should be done by use of a long needle inserted well away from the fluctuant area.

In inflammatory cases, pain inhibition may produce mild weakness of elbow flexion and extension. Sensation and distal pulses are unaffected. Examination findings of other joints should also be normal.