5.7 Bursitis of the elbow

A bursa (Latin for purse or bag) is a small fluid-filled sac lined with synovial membrane providing a gliding plane and/or a cushioning effect between tendon, muscle, and bone. Several deep and superficial bursae around the elbow have been described; however, only a few are of clinical relevance.

Bursitis is the inflammation of a bursa through either mechanical irritation (non-septic bursitis) or infection (septic bursitis).

Inflammation of the lateral and medial epicondylar bursae are rare sequelae of tennis elbow or a subluxing ulnar nerve and respond to treatment of the underlying pathology. The bicipital radial bursa is often the cause for symptoms deep in the cubital fossa. Differentiation of this from tendinitis, a partial tear of the distal biceps tendon, and secondary compression of the posterior interosseous nerve can be difficult and requires magnetic resonance imaging for exact diagnosis and treatment. The clinically most significant elbow bursa is the superficial olecranon bursa (Box 5.7.1).

Olecranon bursitis has a male predominance with a mean age of 45 years, a prevalence of 3:1000, and an incidence of 1:1000 which is seasonal with the peak in summer. The olecranon bursa develops only after the age of 7 years and increases in size thereafter. In up to 54% the history includes a precipitating trauma but other risk factors need to be considered:

The clinical examination should begin with a routine elbow assessment including range of motion, nerve function, and pre-existing elbow pathologies (osteoarthritis, rheumatoid arthritis, and post-traumatic disorders). Localized clinical features of olecranon bursitis include: swelling, erythema, increased skin temperature, fluctuance, and tenderness

Attention should be given to scarring in the elbow region (previous surgery, healed sinuses, haemodialysis) and areas of possible skin breakage (open or healed).

It is important to differentiate between non-septic (more than 60%) and septic bursitis (Box 5.7.2) since early diagnosis is essential for appropriate treatment.

Septic arthritis of the elbow must be considered in the differential diagnosis and when present there is usually a painful reduction of joint movement. Aspiration of the elbow will normally confirm the diagnosis.

If the bursa contains sufficient fluid, an aspiration is recommended in order to exclude or confirm infection. This can guide fast and efficient treatment. Aspiration also enables microscopic examination of the fluid for crystal formation. The extent of further investigations is dependent on the presenting symptoms and may require:

Staphylococcus aureus is the most common organism found in septic olecranon bursitis (85%). Other organisms that may be present include Gram negatives, mycobacteria, as well as fungi. It has been suggested that the clinical spectrum of septic olecranon bursitis differs when it is caused by organisms other than Stapylococcus aureus.

Most cases of olecranon bursitis do not require hospitalization and can be treated ambulatory (Box 5.7.3).

This can be successfully treated with splintage, reducing elbow movements and thereby resting the overlying soft tissues. This should be combined with oral, non-steroidal anti-inflammatory drug (NSAID) treatment. Whilst intrabursal corticosteroid injections can be a very effective treatment option, the concern over local long-term effects remains. Any associated underlying systemic disease such as gout or rheumatoid arthritis must also be addressed if treatment is to be effective. The symptoms in patients with non-septic olecranon bursitis resolve more slowly when compared to septic bursitis.

Early treatment involves a combination of elbow splintage and oral antibiotic therapy. However, once the clinical picture shows advanced signs (Figure 5.7.1) such as local cellulitis, lymphangitis, and lymphadenitis or systemic effects with shivering and fever, the antibiotic therapy should be administered intravenously. The duration of therapy is guided by the response to treatment but prolonged treatment courses are not uncommon.

If the olecranon bursitis remains refractory to conservative treatment or a bursal collection with septicaemia develops, surgical excision of the bursa should be performed. Although normally the initial response to such treatment is good, the complication rate remains a concern for the treating clinician. Recurrence, a chronic discharging sinus, and wound breakdown are common (up to 25%) along with worrisome complications. In order to reduce such problems, several surgical techniques have been described:

If the extent of the bursa is difficult to determine, the use of methylene blue and hydrogen peroxide staining can be used. In an attempt to prevent wound healing problems following resection of the bursa, endoscopic techniques with excellent results have more recently been described.

A chronic discharging sinus can initially be treated non-operatively with regular changes of wound dressing in the outpatient department. If signs of infection develop, antibiotic therapy is required and is based on the culture and sensitivity report.

Should the sinus remain refractory to such treatment, revision surgery should be contemplated. The use of talcum powder in revision surgery has shown favourable results. For chronic and recurrent wound breakdown, more advanced reconstructive soft tissue techniques, such as local and free flap, may be required.