Olecranon bursitis– Considerations relating to diagnosis
Link to NICE CKS 2017 definitions and diagnostic considerations; https://cks.nice.org.uk/olecranon-bursitis#!backgroundsub:1
Key points from the above documents (not exhaustive)
- Non-septic bursitis usually results from either:
- Trauma or overuse – a single, direct blow to the elbow or repeated mild trauma, such as leaning on the elbow, may cause olecranon bursitis. Inflammation occurs because of bleeding into the bursa or through the release of inflammatory mediators after trauma
- Systemic conditions – most commonly gout or rheumatoid arthritis (intra-bursal rheumatoid nodules); rarely conditions such as ankylosing spondylitis, systemic lupus erythematosus, or scleroderma
- Septic bursitis usually occurs when bacteria (or, rarely, other micro-organisms) enter the bursa. The olecranon bursa is more likely than other bursae to become infected because it is superficial and the overlying skin is prone to minor injuries, which can provide an entry point for micro-organisms
- It may be difficult to clinically differentiate between septic and non-septic bursitis.
- Features that may indicate septic bursitis include: Increased tenderness or painful, red, hot swelling of the bursa which is progressively worsening; Local cellulitis; abrasion or laceration over the bursa; Fever; Immunocompromised state; Seeking medical help soon after the onset of swelling; Other signs of septic olecranon bursitis may include:Tachycardia; Low blood pressure; A change in mental status.
- Olecranon bursitis is more common in: Young and middle-aged men; People with occupations which involve risks of regular elbow trauma or pressure on the bursa, such as gardeners, carpet layers, mechanics, plumbers, roofers, truck drivers, students or people writing on a regular basis; Athletes who play sports which involve repetitive overhead throwing or elbow flexion and extension, or direct impact onto the elbow (such gymnastics, weightlifting, rugby, football, or hockey)
- Olecranon bursitis may occur more rarely in: People with chronic lung problems (who often rest their elbows against a hard surface at the level of the lower rib cage to increase inspiratory effort)
- Consider differential diagnosis- The localized swelling of olecranon bursitis is usually distinctive, but conditions that may appear clinically similar include:
- Rheumatoid arthritis – the whole joint is inflamed, rather than a localized, fluctuant swelling over the olecranon process. Nodules may cause swelling over the olecranon region, but they are firm with no fluctuance. Other joints may also be affected.
- Septic arthritis – the joint is swollen (with absence of localized bursal swelling) and there is a limited, painful range of movement on joint examination. Secondary septic arthritis can also be a rare complication of olecranon bursitis.
- Gout or, rarely, pseudogout – joints (for example the first metatarsophalangeal joint in gout, or knee or wrist in pseudogout) may have been affected in the past, and laboratory examination of aspiration fluid will show crystals. Acute gout may occur in the bursa with or without local tophi.
- Cellulitis – this may coexist with septic olecranon bursitis.
- Tennis elbow (lateral epicondylitis)
- Trauma (such as a fracture, tendon or ligament injury) – the history is usually indicative of more significant trauma.
- Local bone or soft tissue tumours – these can be clinically similar to any local bursitis, with pain, swelling, and erythema. Findings suggestive of neoplasia, such as rapid expansion, overt invasive skin changes, and weight loss, should be observed with suspicion as recurrent sarcomas have been initially misdiagnosed as olecranon bursitis.
