Superficial Bursitis

Olecranon Bursitis (Draftsman’s Elbow)

50 y/o plumber with h/o alcoholism, immunocompromised state, DM and end-stage renal disease on hemodialysis presents with acute onset, mildly tender unilateral elbow swelling after repeatedly striking the affected elbow against pipes while working. Pt can expel serous fluid from lesion with minimal manipulation, but swelling returns within a few hours. Denies fever, chills. Denies personal, family history of rheumatologic disease and/or gout. Bursal enlargement with mild tenderness and surrounding edema noted on exam. Decreased ROM due to swelling, but not pain.

Prepatellar Bursitis (Housemaid’s Knee)

Presentation is similar to olecranon bursitis, but microtrauma is due to frequent kneeling/crawling. Associated professions/activities include plumbers, roofers, wrestling, and gardening.

Aseptic Bursitis

• Significant bursal enlargement

  • Consider aspiration of elbow/knee for symptom relief; if performed, obtain BMP and send aspirate for analysis

  • Aspirated fluid serosanguinous with

    • < 1,500 WBC/mm^3 and fluid:serum glucose ≥ 0.5

    • No crystals and negative Gram stain/culture

• Imaging

  • Ultrasound shows enlarged bursa, thickened bursal sac

  • Color Doppler negative for hyperemia

  • Recent trauma or concern for foreign body: Obtain plain radiography

• Initial management

  • Rest, ice, and elevation to resolve acute swelling

  • Naproxen 500 mg BID for swelling and pain

  • Elbow padding to reduce future trauma

• If swelling persists or is bothersome to the patient, consider intralesional corticosteroid injection vs. referral to orthopedics for surgical bursectomy

• Pt instructed to contact provider if s/sx of septic bursitis develop (see below)

Septic Bursitis

Pt returns with increased pain and decreased ROM at the bursitis-affected elbow. Reports skin trauma at bursa site due to repeat attempts to aspirate sac at home. Fever, erythema, surrounding edema, and tenderness to palpation noted on exam. Temperature of skin overlying bursitis 2°C greater as compared to non-affected elbow.

• Obtain CBC, CMP, ESR, CRP, and blood culture

• Cloudy/purulent aspirate shows > 1,500 WBC/mm^3, fluid:serum glucose < 0.5, positive Gram stain, no crystals; f/u culture results

• Start cephalexin 500 mg q6h x 10 days and adjust therapy pending culture

• Imaging

  • Ultrasound shows enlarged bursa +/- surrounding cellulitis

  • Hyperemia on color Doppler indicating infection

  • Bursa aspiration unsuccessful: Obtain MRI

• Failed outpatient management and/or concern for systemic infection: Admit to hospital, start vancomycin, and consult orthopedics

Notes

• Differential diagnosis includes rheumatoid arthritis and gout

• Olecranon bursitis

  • Most common in patients with repeat elbow microtrauma, e.g. students, draftsmen, plumbers, technicians, and miners

  • Increased prevalence in hemodialysis patients; the pathophysiology responsible for this association is unknown

• Septic bursitis

  • 80-85% of cases associated with S. aureus

  • Risk factors

    • Patients with h/o alcoholism, immunocompromised state, DM, and ESRD

    • Skin injury at or near bursa site

    • Repeat attempts to aspirate bursa at home