Definition

Olecranon bursitis is a swelling of the subcutaneous, synovium-lined fluid-filled sac located posteriorly over the olecranon process of the ulna and the triceps tendon. The bursa serves as a cushion between the tip of the olecranon and the overlying skin. Because of its location, the olecranon bursa is particularly susceptible to injury and olecranon bursitis is one of the most common forms of superficial bursitis.

Olecranon bursitis can be classified as acute, chronic, or septic. The most common etiologies include trauma and pre-existing systemic medical conditions. For example, acute bursitis can result from direct trauma, prolonged pressure, or microcrystalline disease. Chronic bursitis is usually secondary to overuse/microtrauma or systemic disorders. Septic olecranon bursitis is almost always associated with trauma and represents approximately 20% of cases.

Trauma can lead to bursitis from a single, direct blow to the elbow or from minor repetitive stress. Trauma is thought to stimulate increased vascularity, resulting in bursal fluid production and fibrin coating of the bursal wall. Persons engaged in certain occupations or activities are susceptible to olecranon bursitis due to prolonged pressure or repetitive stress with microtrauma, including auto mechanics, gardeners, plumbers, carpet layers, students, gymnasts, wrestlers, and dart throwers. Interestingly, approximately 7% of hemodialysis patients develop olecranon bursitis. Repeated, prolonged positioning of the elbow and anticoagulation appear to be contributing factors. Trauma can also lead to septic olecranon bursitis, allowing for transcutaneous inoculation of the bursa.

Inflammatory causes of olecranon bursitis include systemic diseases such as rheumatoid arthritis, systemic lupus erythematosus, microcrystalline disease, and chondrocalcinosis. Olecranon bursitis is commonly seen in rheumatoid patients, in whom the bursa may communicate with the affected elbow joint. The olecranon bursa is one of the most affected bursae in microcrystalline diseases.

In septic olecranon bursitis, the source is most often transcutaneous, with about half of affected individuals having an identifiable break in the skin. Hematogenous seeding is thought to be rare, as the bursa has a limited blood supply. When bursal fluid culture samples are positive, Staphylococcus aureus and β-hemolytic Streptococcus are the first and second most common causative agents, respectively. Resulting sepsis is unusual. There appears to be a seasonal trend, with a peak of staphylococcal septic bursitis during the summer months. Many pre-existing diseases are risk factors for septic olecranon bursitis, including microcrystalline diseases, rheumatoid arthritis, diabetes mellitus, uremia, and psoriasis. Alcoholism, injection drug use, and steroid/immunosuppressive therapy are also considered predisposing factors.

Symptoms

A detailed history focusing on presenting symptoms, risk factors (including occupation, hobbies, medical history), recent trauma, and the possibility of infection or neoplasm is key. Commonly reported symptoms with olecranon bursitis are swelling, redness, and variable tenderness. These symptoms have been found to be inadequate to differentiate between nonseptic and septic arthritis. However, fever has only been reported in septic bursitis. Other potential signs of infection include anorexia, lethargy, and night sweats. When associated pain is present, patients usually have discomfort when the elbow is flexed beyond 90 degrees secondary to stretching of the bursa and also have trouble resting on the elbow. Neoplasm should be considered on the differential diagnosis and factors including rapid growth, weight loss, history of neoplasms, or failure of initial treatment suggest need for further investigation.

Physical Examination

The physical examination can vary somewhat, depending on the underlying condition. With acute bursitis, a fluctuant mass is present over the tip of the elbow ( Fig. 25.1 ). With chronic bursitis, the fluctuance may be replaced with a thickened bursa ( Fig. 25.2 ). However, like symptom presentation, differentiating between nonseptic and septic bursitis based on physical exam can be difficult due to significant overlap. Both conditions may produce tender fluctuance, induration, swelling, warmth, and local erythema. Elbow flexion may be somewhat limited by pain, although not as limited as with septic arthritis of the elbow joint. No pain or changes in range of motion are typically seen with elbow extension. A break in the skin over the elbow and overlying cellulitis are important clues to a potential underlying septic process. 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.

Atraumatic olecranon bursitis in a 55-year-old woman. A large, fluctuant mass is present.

Chronic gouty olecranon bursitis. The prominence at the tip of the elbow is firm with thinning of the overlying skin.

Functional Limitations

Functional limitations can vary. Many cases of traumatic olecranon bursitis have minimal associated functional limitations. Patients may note some mild discomfort with direct pressure over the tip of the elbow (e.g., when sitting at a desk or resting the arm on the armrest of a chair or in the car). With crystal-induced and septic bursitis, pain can be more limiting. Patients may have trouble sleeping and have difficulty with most activities of daily living that involve the affected extremity (e.g., dressing, grooming, cleaning, shopping, and carrying packages).