Septic Olecranon Bursitis: Recognition and Treatment Donald Shell, MD, Rob Perkins, MD, and Andrew Cosgarea, MD

L£ * ill gl J Am Board Fam Pract: first published as 10.3122/jabfm.8.3.217 on 1 May 1995. Downloaded from Septic Olecranon Bursitis: Recognition And Treatment Donald Shell, MD, Rob Perkins, MD, and Andrew Cosgarea, MD Background: The superficial location of the olecranon bursa places it at high risk for injury, possibly leading to the entry of bacteria into the bursal sac. Early differentiation between septic and nonseptic olecranon bursitis is paramount to direct therapy, to hasten recovery, and to prevent chronic inflammation. Methods: Aliterature review was perfonned using MEDLINE files from 1967 to the present. Additional references from the bibliographies of these were also utilized. Results and Conclusions: Olecranon bursitis is a common condition that requires the treating physician to be aware of the predisposing factors, clinical signs and symptoms, and laboratory findings of both septic and nonseptic olecranon bursitis. With early recognition, prompt therapy, and preventive measures, the morbidity of septic olecranon bursitis can be considerably reduced, but surgical incision and drainage or excision could be required if conservative therapy fails. (J Am Board Fam Pract 1995; 8:217-20.) Bursae are closed, saclike structures that produce Case Report small amounts of fluid allowing for smooth and A National Collegiate Athletic Association Divi almost frictionless motion between contiguous sion I college basketball player struck his left 1 muscles, tendons, bones, ligaments, and skin. ,2 elbow on the hardwood court while falling during The superficial location of the olecranon bursa a game. Because of pain and swelling of his left puts it at high risk for injury, possibly leading to elbow, the next morning he sought treatment at a the entry of bacteria into the bursal sac.3 local emergency department. There was localized Olecranon bursitis is common in athletes who swelling of his left olecranon bursa with indura play basketball, football, soccer, and hockey as a tion and erythema restricted to the bursal area. result of the athlete falling and striking an elbow No abrasions or skin lesions were visible. on hard playing surfaces,2 which can lead to in His elbow had full pronation, supination, and flammation (bursitis) within the olecranon bursal flexion, with terminal extension loss secondary http://www.jabfm.org/ sac. Occasionally an inflamed bursa can also be to pain. Radiographs of the left elbow showed come infected, requiring differentiation between soft tissue swelling of the bursa but no bony in septic and nonseptic bursitis. jury. The bursa was aspirated under sterile condi Most cases of nonseptic olecranon bursitis are tions in the emergency department and 3 mL of due to overuse injury and are seen in athletes who cloudy fluid were drained and sent for Gram stain play sports that involve repetitive overhead throw and culture. No organisms were seen on Gram ing and elbow flexion and extension, such as base stain. He was discharged from the emergency de on 23 September 2021 by guest. Protected copyright. ball, swimming, skiing, gymnastics, and weight lift partment with a compression dressing around the ing.4 Direct trauma to the elbow is also a common left elbow. Twenty-four hours later, the culture cause of olecranon bursitis as a result of repeated grew Staphylococcus aureus and 750 mg of oral scrapes and falls on artificial turf, wrestling mats, ciprofloxacin was prescribed to be taken every hardwood floors, ice, and exercise mats.2 Both over 12 hours. use injury and trauma to the bursa lead to inflam After 4 days of oral ciprofloxacin, compression mation, effusion, and thickening of the bursal wall,5 wraps, ice, elevation, and rest, he continued to ex perience pain, swelling, spreading erythema, de creased range of motion, and warmth of the left Submitted, revised, 24 October 1994. elbow area. He was admitted to the hospital for From the Department of Family Medicine (DS, RP), and the intravenous antibiotics. Department of Orthopaedic Surgery (AC), The Ohio State Uni At the time of admission he was afebrile, but versity, Columbus. Address reprint requests to Donald Shell, MD, Section of Primary Care, Department of Medicine, Lenox the erythema had extended proximally to the left Hill Hospital, 100 E. 77th Street, New York, NY 10021-1883. upper arm and distally to the extensor surface of Septic Olecranon Bursitis 217 -.~.--.-.-~ ...----- .. -"- ..-._-----_.- -.-~~-- the forearm. There was extreme tenderness to Discussion J Am Board Fam Pract: first published as 10.3122/jabfm.8.3.217 on 1 May 1995. Downloaded from palpation at the olecranon bursa and warmth over The development of a septic bursitis depends on the entire affected area, but no epitrochlear several predisposing factors. The most important or axillary lymphadenopathy. Complete blood is a history of trauma to the bursa, with transcuta count with a differential leukocyte count was neous bacterial contamination.l With its superfi normal with a white cell count of 8800/1J.L. We cial location and high injury rate, the olecranon concluded that the septic olecranon bursitis had bursa is the most common site for septic bursitis worsened to include cellulitis of the left arm and to occur.l Local or distal skin disruption is com forearm. monly seen near the area of elbow trauma. Even We prescribed intravenous nafcillin, 2 g every in elbow trauma with no visible skin abrasions, 6 hours, and during a 3-day hospitalization, the avenue for bacterial infection is still most his erythema, tenderness, warmth, and swelling likely through the skin. l Other predisposing fac diminished. At the time of discharge the ery tors for the development of a septic bursitis in thema, warmth, and induration had almost com clude frequent pressure on the bursa, an immuno pletely resolved; there was mild tenderness over compromised state (human immunodeficiency the bursa area, and full active range of motion was virus infection, oral corticosteroid therapy), rheu observed. Near terminal extension of the elbow matoid arthritis, systemic lupus erythematosus, yielded mild pain. He remained afebrile through and gout.6-10 out the hospitalization. At the time of discharge oral ciprofloxacin, 750 mg twice a day, was pre Organisms Associated with Septic Bursitis scribed based on laboratory sensitivities. He was The organism most frequently identified in sep instructed in mild range-of-motion exercises of tic olecranon bursitis is Staphylococcus aureus, the left elbow and advised not to play basketball which is present in 72 to 92 percent of the infec until pain was completely gone and to avoid fur tions, l,6-8,1l,12 reflecting that bacterial seeding ther trauma to the elbow. of most cases of septic olecranon bursitis occurs Upon attempting to shoot baskets on the 2nd transcutaneously. In cases of systemic illnesses or and 3rd day after discharge, he developed worsen an immunocompromised state, however, case ing pain and was readmitted to the hospital with a reports of rare types of organisms have been markedly tender, swollen, and fluctuant left olec documented. ranon bursa. There were palpable enlarged Cryptococcus neoformans was identified as the epitrochlear but no axillary lymph nodes. In view causative organism for olecranon bursitis in a http://www.jabfm.org/ of the failure of conservative therapy of compres patient with cirrhosis.13 A patient with diabetes sion wraps, ice, rest, closed-needle aspiration, and mellitus type II was reported to have an olecranon both oral and intravenous antibiotic therapy, the bursitis caused by Aspergillus terreus. Both of these decision was made for surgical excision of the left cases emphasize the importance of organism olecranon bursa. At surgery the bursa was thick identification in immunocompromised patients 10 ened and edematous, but there was no evidence of with a septic olecranon bursitis. on 23 September 2021 by guest. Protected copyright. infection in the surrounding tissues. Microscopic examination of the 3.5 X 3.0 X O.S-cm bursa re Differentiation between Septic and Nonseptk vealed florid granulation tissue formation and Olecranon Bursitis fibrin deposits consistent with a microscopic The most common clinical findings with septic diagnosis of acute and chronic bursitis. Stains for olecranon bursitis are bursal swelling, pain, acid-fast organisms, culture and stains for fungi, erythema, tenderness, and tissue warmth.1,6,14 In and a tissue Gram stain were negative. The a study by Ho and colleagues, 1 bursal swelling patient was discharged on the second postopera and pain were present in 100 percent and 92 per tive day with no signs of active infection, minimal cent of septic olecranon bursitis cases, respec pain, and a compressive dressing in place. We tively. A surrounding cellulitis often accompanies prescribed ciprofloxacin, 750 mg twice a day, and the septic olecranon bursitis1,7,8 as much as 89 on postoperative day 7 he was allowed to begin percent of the time.7 The presence of fever varies, light activity; 2 weeks postoperatively he returned ranging from 15 percent in a study by Pien, et al.8 to competition. to 86 percent in a Scandinavian hospit~l series. IS 218 JABFP May-Junel995 Vo1.8No.3 ~- ---------------------------------------------------------....................... Joint motion, including rotation, is usually pain the initial antibiotic of choice is a penicillinase J Am Board Fam Pract: first published as 10.3122/jabfm.8.3.217 on 1 May 1995. Downloaded from 6 less except for full flexion and extension. I resistant semisynthetic penicillin. A 2-week In comparison with nonseptic bursitis, patients course is necessary for successful resolution of the with septic bursitis seek medical attention sooner, bacterial infection.6,1l Immunocompromised pa are more likely to be febrile, have a bursa that is tients must undergo treatment longer to guaran more often tender to touch, develop a cellulitis of tee a successful outcome.3 Outpatient treatment the surrounding skin, and more frequently have with oral antibiotics is effective in patients with overlying skin lesions.

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