Growth Plate Fractures

The physeal plate is a cartilaginous plate present in ends of long bones, adjacent to the metaphysis. This is the area that provides longitudinal growth to bones and eventually matures into bone. During growth, the physeal cartilaginous plate is weaker than the surrounding bone and often weaker than the ligaments and tendons that attach nearby, causing it to fracture before other areas. The Salter-Harris classification system describes these injuries (Fig. 30-2).

Figure 30-2 Types of growth plate injury (I to V) as classified by Salter and Harris.

(From Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg (Am) 1963;45:587.)

Injuries of Clavicular Complex

Key Points

The diagnosis of clavicle, acromioclavicular, and sternoclavicular injuries is straightforward; direct palpation along the clavicular complex should lead to an area of focal pain. Imaging studies should include the entire clavicle and a clear view of the targeted area from at least two planes. All injuries around the shoulder should include examination of the cervical spine and distal neurovascular evaluation. The brachial plexus, subclavian vein, and axillary artery lie immediately beneath the clavicle and can be at risk of injury.

Clavicle fractures account for 5% to 10% of all fractures and can be classified as either displaced or nondisplaced as well as by their specific location (proximal-distal) on the clavicle. Most fractures involve the midshaft (80%); however, distal third (15%) and proximal third (5%) fractures are also possible. Fortunately, most clavicle fractures can be definitively treated nonoperatively with a sling or a figure-of-8 dressing if they are minimally displaced or nondisplaced. Figure-of-8 bracing has been linked with skin necrosis over the fracture site, indicating the need for careful observation of skin integrity when used. In most cases, a simple sling for comfort is adequate over the first few weeks, followed by progressive range of motion (ROM) activities. More significant displacement (>100%), any tenting of the skin, significant comminution, or excessive shortening (>2 cm) may warrant surgical intervention, and referral to an orthopedist is recommended. Distal clavicle fractures have a higher rate of nonunion with nonsurgical treatment than midshaft or medial fracture patterns, so careful follow-up is necessary (Kahn et al., 2009; McKee et al., 2004).

Acromioclavicular Joint

Acromioclavicular (AC) joint injuries are classified by the ligamentous structures involved and the degree of separation of the AC joint (Fig. 30-3). A grade 1 injury involves only a partial injury to the AC ligaments, no displacement occurs, and the coracoclavicular (CC) ligaments are intact. A grade 2 injury involves the complete injury of the AC ligaments, and therefore mild superior translation of the distal clavicle occurs (<100% translation), and CC ligaments are intact. Both grade 1 and grade 2 injuries have an excellent prognosis with conservative treatment, which includes local application of ice, reduction of stresses, and a sling for comfort. Most patients will have substantial active motion and functional use of the arm within 6 weeks. A grade 3 involves the complete rupture of both AC and CC ligaments. The distal end of the clavicle and acromion are now separated by more than a full clavicular width (>100% displacement). Stress radiographic views may magnify this separation even further; however, stress views rarely alter the treatment plan and are painful to patients and thus no longer considered required diagnostic images.

Figure 30-3 Progressive severity of acromioclavicular (AC) joint injuries. Grade 1 indicates incomplete injury of ligaments. Grade 2 has complete injury of the AC ligaments but intact coracoclavicular (CC) ligaments. Grade 3 injuries have complete injury of both AC and CC ligaments. Grade 4, 5, and 6 injuries are progressively severe, with posterior displacement of clavicle, severe superior displacement of clavicle, and inferior displacement of clavicle beneath the coracoid process.

Treatment of grade 3 AC injuries is controversial and ranges from surgical to conservative treatment with a sling. With conservative treatment, the distal clavicle may ultimately heal in a superiorly translated position, leaving a prominent bump over the lateral aspect of the shoulder. However, nonelite athletes can function well and have a full return to activities. Acute repair of grade 3 injuries is suggested more for elite athletes, but has not been proved in randomized, controlled trials (RCTs) because subtle changes occur at this important point in the kinetic chain. Chronic reconstructions have been suggested in patients who have grade 3 injuries but with residual pain or dysfunction. The more severe injuries of the AC joint have significant posterior, superior, or inferior displacement and require surgical reduction and repair.

A grade 4 AC separation is a complete injury of both AC and CC ligaments with a posterior subluxation of the distal clavicle relative to the acromion. These are frequently missed on routine anteroposterior (AP) radiographs but can be easily identified if routine axillary shoulder views are obtained. Fundamental management of bone and joint injuries requires a view from two perspectives. Grade 5 injuries are basically equivalent to severe grade 3 injuries where the distal clavicle is riding so high that it either buttonholes through the fascia or tents beneath the skin (300% translation). The fascial injury prevents reduction, and the pressure on the undersurface of the skin risks skin slough or an open injury. Finally, grade 6 AC injuries are extremely rare and are associated with an inferior dislocation of the distal clavicle beneath the coracoid.

Sternoclavicular Joint

Patient with sternoclavicular (SC) injuries present with a history of trauma (e.g., landing on lateral aspect of shoulder) or a history of chronic overuse that has led to popping and pain over the medial aspect of the clavicle (Matave et al., 2005). Acute SC joint dislocations can be identified clinically with localized tenderness over the medial clavicular aspect, and gross deformity may be present. More often, however, patients present with a subtle chronic situation caused by esthetic findings with a palpable or gross asymmetry. The examination should always include an assessment of the patient’s airway and circulation, including cervical venous distention, because the great vessels and trachea lie immediately posterior to the SC joints (Fig. 30-4). Imaging studies should include an AP radiograph of the chest, views of the entire clavicle, and a tangential or serendipity view of the SC joint (Fig. 30-5). Because of overlapping shadows, these studies may be difficult to interpret. When suspicious, the best test is computed tomography (CT).

Figure 30-4 Drawing shows proximity of major neurovascular structures to sternoclavicular joint.

Figure 30-5 Technique in obtaining a tangential radiographic image, the serendipity view, to assess sternoclavicular joint injuries.

Traumatic SC joint dislocations can be either anterior or posterior. Anterior dislocations are generally easily palpated, with the proximal clavicle anteriorly displaced and painful. Anterior injuries may be reduced by placing a rolled towel or beanbag between the shoulder blades, then creating a distraction force along the arm in extension. Anterior dislocations tend to be unstable and to redisplace after attempted reduction. Fortunately, anterior injuries usually heal uneventfully, leaving an asymptomatic medial prominence and occasional popping, with minimal effect on the patient’s activities of daily living. Posterior dislocations can be dangerous because of proximity to the great vessels posteriorly. If patients have venous engorgement in the neck and difficulty breathing, closed reduction may be attempted. A towel clip is used at the medial end of the clavicle, pulling anteriorly and creating the reduction. If this is attempted, a vascular surgeon should be available in case the proximal clavicle was actually tamponading an injury to the great vessels. This reduction should never be performed on the sideline in the absence of immediate cardiothoracic surgical response, unless the patient’s life is at risk and there is no other option.

When treating injuries to the proximal clavicle, age of the patient and normal maturation of the proximal epiphysis are also important considerations. The medial clavicle epiphysis is one of the last to appear, at 19 to 23 years of age, and then the last to fuse, at 23 to 25 years of age. In patients younger than 23, these injuries are generally physeal injuries and not true dislocations, reducing the need for aggressive treatment (Fig. 30-6).

Figure 30-6 Medial clavicle injuries in patients younger than 23 to 25 years are likely physeal injuries and have the potential to remodel.

KEY TREATMENT

Subacromial injection for rotator cuff disease or intra-articular injection for adhesive capsulitis may be effective, although the effect may be minimal and not well maintained (Buchbinder et al., 2003) (SOR: A).

The use of some physiotherapy interventions is indicated in specific and circumscribed cases of shoulder pain (Green et al., 2003) (SOR: B).

Little evidence supports the benefit of manual therapy for adhesive capsulitis, shoulder pain, or subacromial impingement syndrome (Ho et al., 2009) (SOR: A).

The use of acupuncture for shoulder pain can be neither recommended nor refuted (Green et al., 2005) (SOR: A).

Shoulder Impingement and Rotator Cuff Disease

Key Points

By far the two most common diagnostic categories about the shoulder are rotator cuff impingement and shoulder instability. The rotator cuff is a group of four muscles—supraspinatus, infraspinatus, teres minor, and subscapularis—that originate from the scapular surface, traverse just outside of the glenohumeral capsule, and insert onto the tuberosities of the humerus (Fig. 30-7). The rotator cuff initiates motion in the shoulder and stabilizes the humeral head in the glenohumeral joint.

Figure 30-7 Anteroposterior (A) and lateral cross-sectional (B) drawings of the shoulder demonstrate the relationship of the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) to the bony structure of the shoulder.

The diagnosis of rotator cuff impingement is actually a continuum of pathologies, including subacromial bursitis, AC joint hypertrophy and spurring, rotator cuff tendinosis, partial rotator cuff tears, complete or massive rotator cuff tears, and ultimately, rotator cuff arthropathy; that is, degenerative disease related to chronic rotator cuff insufficiency (Almekinders, 2001). Patients generally present with shoulder pain exacerbated by repetitive overhead activities, perhaps weakness, and occasionally difficulty sleeping on the shoulder. Physical examination of the shoulder includes provocative maneuvers that exacerbate impingement findings and evaluate the function of each rotator cuff muscle (Tennent et al., 2003a, 2003b). Impingement testing includes straight, forward flexion of the shoulder (Neer sign), abduction and internal rotation of the shoulder (Hawkins sign), and adduction of the shoulder in a 90-degree, forward-flexed position (Figs. 30-8 and 30-9). The examiner must be cautious with the latter test because it may be positive with impingement but also with AC joint hypertrophy alone or with degenerative change of the AC joint.

Figure 30-8 Hawkins test for shoulder impingement is performed by forward-elevating the humerus against the fixed scapula. Pain indicates anterior impingement.

(Courtesy Mark R. Hutchinson, MD.)

Figure 30-9 Neer test for shoulder impingement is performed with abduction and internal rotation of the shoulder. Pain indicates lateral impingement.

(Courtesy Mark R. Hutchinson, MD.)

Isolated testing of the rotator cuff is performed in sequence. To isolate the supraspinatus muscle, the examiner should perform the “empty can” test. This is performed with the arm slightly forward-flexed in the plane of the scapula, abducted to 90 degrees, with full internal rotation (i.e., with thumbs down, or empty can). The examiner should then place resistance on the patient’s distal hand in an inferior direction. If this exacerbates pain, it is a positive finding of impingement or rotator cuff tendinopathy. If the patient has a positive “drop arm” sign, unable to maintain the arm in this position, a complete rotator cuff tear should be suspected. However, this does not confirm a complete rotator cuff tear because the patient may be guarding secondary to pain. Clinically, the examiner can clarify the difference by performing a diagnostic subacromial injection with lidocaine. The injection should significantly diminish pain complaints but not affect the motor function of an intact rotator cuff (Park et al., 2005).

To evaluate the infraspinatus and teres minor muscles, the examiner should evaluate external rotation against resistance. This is best done with the arm at the side, keeping the elbows near the torso, and asking the patient to rotate externally against resistance. Isolating the subscapularis muscle is more difficult. Resisted internal rotation with the arms at the side will recruit the pectoralis muscles and not isolate the subscapularis. To isolate the subscapularis, two tests have been described. In the lift-off test, the patient places the arm behind the back and lifts the hand into further internal rotation against resistance (Fig. 30-10). If able to do this, the patient’s subscapularis muscle is likely intact. Modification of this test has been described as the “tummy pat” or the “Napoleon” test, in which the patient abducts the elbow, which must be away from the body in the plane of the torso, and is then asked to pat the stomach against resistance (Fig. 30-11). Weakness or inability to press against resistance is considered to be a positive test. Once the diagnosis is made clinically, AP and axillary shoulder x-ray studies can be obtained to evaluate the extent of injury further or assess for concomitant injuries. MRI is not routinely indicated with an intact rotator cuff clinically, and we usually recommend trying a course of physical therapy for 6 to 12 weeks before ordering MRI (Park et al., 2005).

Figure 30-10 Lift-off test is used to assess subscapularis muscle function. Patients are asked to lift their hand off their back against resistance. Weakness or pain indicates subscapularis pathology.

(Courtesy Mark R. Hutchinson, MD.)

Figure 30-11 “Napoleon” or “tummy pat” test is a modified lift-off test to evaluate subscapularis function. Patients are asked to maintain their elbow laterally while pressing into their belly. (Ensure that patients do not drop their arm and use their humerus extensors to mimic subscapularis function.)

(Courtesy Mark R. Hutchinson, MD.)

If the patient has intact rotator cuff function on clinical examination and otherwise normal findings on radiographs, a conservative course of physical therapy is indicated for the impingement symptoms. From 90% to 95% of patients with incomplete tears of the rotator cuff improve with the course of physical therapy, anti-inflammatory medications, or a subacromial injection, although some may require surgery eventually (Matava et al., 2005). Physical therapy should focus on rotator cuff strengthening, ROM, posterior capsular stretching, and scapular stabilization. If patients fail a 6- to 12-week course of conservative treatment, a corticosteroid injection should be considered before surgery. If a patient is refractory to both corticosteroids and physical therapy, surgical intervention may be indicated. This is a more appropriate time to order an MR image because preoperative MR scanning can evaluate the extent of rotator cuff pathology, associated spurring, and degeneration within the shoulder joint. Although not necessary for making the diagnosis, MRI can assist the surgeon at surgery.

For incomplete rotator cuff tears (<50% of surface), a partial debridement and subacromial decompression using arthroscopy can provide effective, long-term relief of impingement pain. Management of rotator cuff tears greater than 50% or complete with clinical dysfunction is generally surgical. If the tear is identified before chronic retraction and muscle changes, primary arthroscopic or open repair has been effective in reducing pain and improving function. Rehabilitation after rotator cuff repair requires at least 6 weeks of passive ROM only, to protect the repair, followed by a gradual increase to resistance activities for the rotator cuff. Patients usually begin strengthening at 12 weeks. In patients with nonreparable chronic rotator cuff tears or those with advanced rotator arthropathy and degenerative disease, surgical interventions include muscle transfers, soft tissue grafts, hemiarthroplasties, and reverse shoulder hemiarthroplasties.

Shoulder Instability

Bony anatomy provides minimal stability to the glenohumeral joint; therefore the primary stability depends on both static and dynamic soft tissue structures. The static soft tissue structures include the fibrocartilaginous labrum, glenohumeral ligaments, and capsule. The labrum attaches to the periphery of the glenoid and serves to deepen the socket, reducing translation out of the socket. The glenohumeral ligaments attach to the labrum, are thickenings in the capsule, and connect to the humeral head. The intrinsic dynamic stabilizers are the rotator cuff and biceps, which help to maintain the humeral head in the glenoid socket. The extrinsic dynamic stabilizers include the rhomboid, levator scapulae, serratus, and trapezius muscles, which position the glenoid beneath the humeral head.

The diagnosis of shoulder instability begins with the patient’s history and mechanism of injury, which often include episodes of subluxation, dislocation, or apprehension. Classically, anterior instability is appreciated when the arm is placed in abduction and external rotation (Tennent et al., 2003a, 2003b) (Fig. 30-12). Inferior instability is appreciated when the patient tries to hold a heavy object and the shoulder subluxes inferiorly. Posterior instability is frequently associated with a fall on an outstretched arm, or occasionally with weightlifters who lock out their arms in extension while bench pressing. The clinical examination targets these specific pathologies with the classic apprehension test for anterior instability, performed with the arm in abduction and external rotation, and the patient having the sensation of the arm going out of place. In the relocation test the examiner then presses the humeral head back into a reduced position, thus eliminating the sensation of apprehension. Posterior instability is assessed in a supine position with the arm forward-flexed 90 degrees with a posteriorly directed force. Inferior instability is assessed by pulling inferiorly on the arm and looking for or feeling the humerus come out the socket and looking for a concavity just below the acromion, called the “sulcus sign” (Fig. 30-13).

Figure 30-12 Apprehension test is performed with the arm in full abduction and external rotation. Sensation of impending subluxation is a positive finding. (

Courtesy Mark R. Hutchinson, MD.)

Figure 30-13 Presence or absence of a sulcus sign is evaluated by distracting the arm inferiorly to sublux the humeral head out of the socket. If a sulcus is appreciated as the glenoid is emptied of the humeral head, the clinician should suspect multidirectional instability.

(Courtesy Mark R. Hutchinson, MD.)

Some patients may have generalized ligamentous laxity, but laxity itself is not a painful process and is therefore not pathologic. However, some patients with generalized ligamentous laxity do have symptoms of instability and pathology that can be assessed by comparison to the opposite side or looking at the elbows, fingers/thumb, or knees for excessive recurvatum, In general, patients with generalized ligamentous laxity should undergo an extensive course of conservative treatment because of the increased risk of failure associated with most surgical interventions compared to simple unidirectional instability.

The conservative treatment of shoulder instability is targeted at balancing the flexibility, optimizing the motor strength, and optimizing the function of the kinetic chain. The core component is rotator cuff–strengthening exercises as well as scapular stabilizer exercises. Controversy surrounds the ideal treatment for a first-time shoulder anterior dislocation. In young athletes or military populations, the risk of recurrence and future shoulder problems approaches 90%. Surgical treatment with repair of labral detachments has led to a high rate of return to play and return to performance, with a low risk (<10%) of recurrent instability for a first dislocation. Older nonathletic patients (>40) with first-time dislocation have a reduced risk of recurrent instability (<50%), so surgical treatment is unnecessary. However, if any patient has recurrent instability or pain, surgery to repair the torn capsule or labral lesions is strongly recommended, with outcomes ranging from 75% to 95% good to excellent results. The Bankart procedure is most often performed and involves direct repair of the torn labrum back to the glenoid from which it was detached (Fig. 30-14). Classically, this procedure was performed open, although the current trend is toward arthroscopic assistance.

Figure 30-14 A, Detachment of the anterior inferior labrum (a Bankart lesion). B, Subsequent suture repair.

Posterior instability accounts for only 10% to 15% of isolated instability of the shoulder. The classic treatment for posterior instability is to initiate a course of conservative treatment focused on strengthening the posterior capsular muscles, including infraspinatus and teres minor. If a conservative course fails, surgical treatment can once again address either capsular laxity or posterior labral injuries.

Multidirectional instability is usually not secondary to a single acute traumatic event. More frequently, the patient will have underlying generalized ligamentous laxity that may or may not be exacerbated by a single traumatic event. These patients are generally loose jointed in all directions and in other joints. Initially, treatment is conservative, although in resistant cases, surgical capsular tightening can be successful in improving symptoms. A thorough history is necessary to rule out psychologic factors (e.g., voluntary dislocation for attention or party trick). These patients have an extremely high failure rate with surgical intervention.

Lateral Elbow Tendinopathy

Lateral elbow tendinopathy or lateral epicondylitis, commonly called “tennis elbow,” is caused by repetitive overuse of the wrist extensor and forearm supinator muscles that originate at the lateral epicondyle of the humerus—more specifically, the extensor carpi radialis brevis tendon. Once thought to result from inflammation, lateral elbow tendinosis is probably caused more by chronic changes in the musculotendinous matrix (Nirschl, 1992), with minimal inflammation present, particularly with symptoms present for more than 4 to 6 weeks. Microtears, chronic granulation tissue, and scar tissue formation are often seen in pathologic specimens of surgical cases of tennis elbow.

Patients present because of pain in the lateral aspect of the elbow and may complain of weakness or restricted elbow motion, but this is not as common. Pain is worsened by gripping, turning handles, and lifting activities, particularly with the hand in a palm-down position, as in lifting a suitcase, briefcase, or purse. Common positive physical examination findings include tenderness to palpation of the lateral epicondyle of the elbow and over the proximal wrist extensor and forearm supinator muscle tendons. Pain is intensified with resisted wrist extension and forearm supination. Pain can also limit patient strength. There should be no tenderness directly over the radial head, with normal ligamentous stability and neurovascular status.

Plain radiographs are not needed to make an accurate diagnosis of lateral epicondylitis but should be considered in patients with a history of trauma, motion loss, or locking or with a prolonged period of pain.

Management focuses on pain control and restoration of normal elbow function. Cryotherapy, ice massage, and nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are excellent pain relievers. NSAIDs and corticosteroid injection have been mainstays of treatment, although they are now questioned because inflammation no longer seems a main factor in the injury process. Corticosteroid injections help quickly reduce the pain of lateral elbow tendinosis, but do not alter long-term outcome (Smidt et al., 2002). Cortisone injection may lead to a short-lived increase in pain in a large percentage of patients (Wang et al., 2003).

Counterforce straps can effectively reduce discomfort in some patients (Fig. 30-15). The strap is applied just distal to the area of maximal tenderness. The strap may relieve some of the tension exerted on the affected muscle tendon units during activities, thereby reducing pain. However, straps, medications, and injections should not replace therapeutic exercises, which include massage, stretching, and strengthening exercises. The most effective stretch is performed with the elbow extended, forearm fully pronated, and wrist flexed. From this position, gentle traction is applied to the middle and ring fingers toward the olecranon. Strengthening exercises with light weights for wrist extension and forearm supination can be done.

Figure 30-15 Lateral elbow counterforce brace. Note that wide, nonelastic support is curved to fit the conical forearm shape. This does not allow for full muscular expansion, thereby diminishing intrinsic muscular force on the lateral epicondyle.

(From Morrey BF [ed]: The Elbow and Its Disorders. Philadelphia, Saunders, 1985.)

Most patients with lateral elbow tendinopathy will obtain excellent relief of symptoms with the program just described, although minimal evidence exists to support these plans (Bissett et al., 2005). If these measures do not lead to adequate relief, other protocols can be added. Formal physical therapy is often used in recalcitrant cases. Treatments such as prolotherapy, dry needling, platelet-rich plasma injections, and extracorporeal shock wave therapy are still experimental, and studies have not fully proved their effectiveness. Surgical intervention is sometimes needed and has excellent results.

Medial Elbow Tendinopathy

Medial elbow tendinopathy or medial epicondylitis, commonly called “golfer’s elbow,” is caused by repetitive overuse of the wrist flexor and forearm pronator muscles that originate at the medial epicondyle of the humerus. Patients present due to pain in the medial aspect of the elbow, rarely weakness, and loss ROM. Pain is worsened by gripping and lifting activities, particularly with the hand in palm-up position. Common positive findings include tenderness to palpation of the medial epicondyle of the elbow and over the proximal wrist flexor and forearm pronator muscle tendons. Pain is intensified with resisted wrist flexion and forearm pronation (Fig. 30-16). Patient discomfort often limits strength. Elbow motion, ligamentous stability, and neurovascular status are typically intact.

Figure 30-16 Medial epicondylitis may be diagnosed clinically by pain localized to the medial epicondyle during wrist flexion and pronation against resistance. There is often pain elicited after making a tight fist, and grip strength is usually diminished on the affected side.

(From Morrey BF [ed]: The Elbow and Its Disorders. Philadelphia, Saunders, 1985.)

As with lateral elbow tendinopathy, plain radiographs are not needed to make an accurate diagnosis of medial elbow tendinopathy, but should be considered with a history of trauma, motion loss, locking, or chronic pain. Also similar to lateral epicondylitis, management of medial epicondylitis includes ice, medications, injections, and straps. However, corticosteroid injections are not recommended because of possible ulnar nerve injury. In medial elbow tendinopathy, the most effective stretch is performed with the elbow extended and the wrist and fingers gently pulled into full extension. The forearm can be pronated or supinated. Strengthening focuses on wrist flexion and forearm pronation exercises.

Olecranon Bursitis

Olecranon bursitis is a common cause of painless elbow swelling from repetitive friction of the olecranon against a firm surface or traumatic impact. Patients most often present with a painless swelling at the dorsal tip of the elbow, described as “a golf ball” or “goose egg” (Fig. 30-17). With trauma-induced swelling, pain and a hematoma may be present. Pain, redness, warmth, and lymphadenopathy may accompany septic bursitis. ROM loss, instability, neurovascular compromise, and strength loss are uncommon. On examination, there is a soft, fluctuant area of swelling directly over the olecranon. Diagnostic studies are generally not necessary to make a diagnosis of olecranon bursitis. However, plain radiographs should be obtained if trauma preceded the bursitis or fracture or dislocation is suspected.

Figure 30-17 A, Relation of the olecranon bursa to the skin and olecranon. B, Photograph of an enlarged olecranon bursa.

(From Singer KM, Butters KP: Olecranon bursitis. In Delee JC, Drez D [eds]. Orthopedic Sports Medicine: Principles and Practice, vol 1. Philadelphia, Saunders, 1994, pp 890, 892.)

Treatment includes compression, ice, and avoidance of impact at the olecranon. NSAIDs may help to reduce swelling. If the fluid collection is large or infection is suspected, aspiration of the bursa can be done in the office with a large-bore needle under sterile conditions. The bursa fluid should be clear and straw colored but may be bloody in a traumatic injury. If an infection is not suspected clinically once the fluid is withdrawn, a corticosteroid can be injected. Corticosteroids should never be injected if infection is a possibility. Oral antibiotics can be started if an infection is present. A local incision and drainage (I&D) may be required in the presence of an infection and abscess. Aspiration does not replace compression wrap, ice, and avoidance of impact. Fluid may reaccumulate but should decrease. Serial aspirations are an option in a recurrent aseptic bursitis, but bursectomy is occasionally needed for definitive treatment.