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.
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.
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.
According to the Habermeyer Classification the fractures to the proximal humerus are divided into:
Type 0 one fractured part without dislocation
Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion
Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities
Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.
These are defined further as:
One-part fractures are non-displaced fractures or fractures with minimal displacement
Two-part fractures only involve a single segment
Three-part fractures involve two segments
Four-part fractures occur when all humeral segments are involved (see image in pathology section)
The injury severity is proportional to the increasing number of fractures.
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)
Prolonged pressure on the elbow (aseptic)
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
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
Mild impaired range of movement of the elbow joint
Fever, general unwell, break of the skin in case of infection
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
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.
Conservative treatment is the most common approach to manage an olecranon bursitis. It consists of:
Application of ice pads, compression, arm elevation
Aspirations (1 or 2) of the fluid accumulated in the bursa
Administration of NSAID’s
Local steroids injection to reduce inflammation in aseptic bursitis
Administration of antibiotics in case of septic bursitis
Elbow protection with pads
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 arising from olecranon bursitis include:
Infection, requiring antibiotic treatment
Reduced elbow extension
Ulnar nerve injury
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.
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.