Olecranon bursitis
The swelling of the olecranon bursa is easily visible on the elbow

Definition

Olecranon bursitis, commonly called elbow bursitis, consists of the inflammation and collection of fluid in the bursa, a fluid-containing membrane located under the skin at the posterior end of the elbow above the olecranon.

Drawing of the inflamed bursa situated below the olecranon bone

Pathology

Olecranon bursitis is a frequent condition caused by the inflammation of the bursa, which is a soft cushion located at the proximal end of the ulna, named olecranon. Generally a bursa facilitates the gliding of the bones during joint movement. As a result of prolonged inflammation of the membrane, the bursa becomes swollen and reddish triggering significant pain with movement of the elbow.

A fall on the elbow with a skin injury can cause a septic infection of the olecranon bursa

Classification

Aseptic bursitis is usually caused by trauma or prolonged pressure on the elbow with specific activities. Injuries to this area can damage vessels and lead to accumulation of blood in the bursa.

Septic bursitis involves the infection of the bursa. This occurs when the skin of the elbow breaks allowing bacteria to infiltrate the sac. Ongoing infection results in the accumulation of fluid, redness, swelling and pain. When advanced, it can lead to pus formation in the bursa.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Frequent leaning on the elbows may lead to an olecranon bursitis

Causes

Olecranon bursitis can arise from an injury to the elbow, prolonged leaning on the elbows during physical work and an infection caused by a laceration to the elbow. It also occurs in patients with medical conditions that affect the joints such as gout and rheumatoid arthritis.

Various mechanisms can lead to olecranon bursitis:

Acute direct injury (aseptic)

Repetitive microtraumas

Prolonged pressure on the elbow (aseptic)

Infection (septic)

 With repetitive strenuous work of the arm and elbow, carpentry is a risk factor for olecranon bursitis

Risk factors

The most frequent risk factors for the development of olecranon bursitis are:

Overuse of the elbow

Leaning on the elbow during carpentry

Medical conditions (rheumatoid arthritis, gout, psoriasis, diabetes, thyroid disease, steroid use)

Life style (alcohol/drug abuse)

Injury to the skin around the elbow causing infection of the bursa

Presence of a bone spur at the olecranon

Typical symptoms of olecranon bursitis

Symptoms

Olecranon bursitis causes a number of symptoms including pain especially when applying manual pressure on the olecranon. Typical symptoms of this pathology are:

Swelling of the tip of the elbow

Redness

Local heat

Mild impaired range of movement of the elbow joint

Fever, general unwell, break of the skin in case of infection

MRI scan showing a thickened, inflamed olecranon bursa

Diagnosis

The clinical presentation of symptoms is usually the optimal method for the diagnosis of olecranon bursitis. Physical examination begins with the medical history including information on professional and physical activities as well as injuries that may have caused the olecranon bursitis. The examiner looks for the presence of deformities, swelling and bruises around the elbow and establish pain level with passive movement of the elbow. In addition it is advised to assess:

Pain during active / passive movements of the elbow

Tenderness at touch

Skin lacerations

Microbiological tests of the bursar fluid if an infection is suspected

Blood tests for diagnosis of gout and other medical conditions

X-rays may be recommended to determine the possible growth of a bone spur causing recurrent bursitis or a fracture of the olecranon. Ultrasound may be employed in case of soft tissue damage and inflammation to surrounding tendons. MRI is only used rarely when other pathologies coexist with olecranon bursitis.

 

Treatment

Local injection of steroids reduces inflammation of the olecranon bursa

Nonoperative treatment

Conservative treatment is the most common approach to manage an olecranon bursitis. It consists of:

Rest

Application of ice pads, compression, arm elevation

Aspirations (1 or 2) of the fluid accumulated in the bursa

Administration of NSAID’s

Pain killers

Local steroids injection to reduce inflammation in aseptic bursitis

Administration of antibiotics in case of septic bursitis

Elbow protection with pads

Surgery aims at removing the thickened bursa

Surgical treatment

If symptoms do not improve with conservative treatment, surgical removal of the inflamed bursa or bursectomy may be necessary. For this procedure an incision is made over the tip of the elbow, the thickened bursa is excised and the skin closed with stitches. Septic surgery of the infected bursa is performed if antibiotics fail to improve the condition. 

Surgery is required in more complicated and displaced olecranon fractures or in case of open fractures whereby the laceration/bone fragments are cleaned up to reduce the risk of infection. An incision in the back of the elbow allows the surgeon to access the fracture. Open reduction and internal fixation is achieved with various devices relative to the shape of the fracture (pin, wires, plates, sutures of the bone) in order to reconnect the bone parts. If fragments of the fractured bone are excised during surgery mostly in elderly, osteoporotic patients, the triceps tendon is reattached to the olecranon. Importantly, removal of over 50% of the olecranon causes elbow instability. Occasionally bone replacement material may be required to substitute lost bone. This procedure includes the use of autologous bone taken from the pelvic crest or artificial bone and cadaver bone transplant. 

Complications

Complications arising from olecranon bursitis include:

Bleeding

Prolonged pain

Recurrent swelling

Infection, requiring antibiotic treatment

Elbow stiffness

Reduced elbow extension

Ulnar nerve injury

Physiotherapy helps to restore elbow function

Rehabilitation

Olecranon bursitis normally does not impair the function of the elbow; therefore a physical therapy is not required. However, some exercises can be recommended to improve the range of motion of the elbow after a short immobilisation post-surgery.

An elastic band placed on the elbow helps preventing olecranon bursitis during activity

Prevention

Simple preventative measures will reduce the onset or recurrence of olecranon bursitis:

Avoid excessive pressure on the elbows by modifying activities and posture

Avoiding falls in the older populations

Minimise the risk of sport-related trauma

Use of suspension pads to cushion and protect the olecranon when leaning on the elbow or in sport practice.