Olecranon Bursitis
Summary
Olecranon Bursitis is inflammation of the bursa (fluid-filled sac) overlying the olecranon process at the tip of the elbow. It is a common cause of elbow swelling seen in primary care and emergency departments. Known colloquially as "Student's Elbow" (from leaning on books) or "Miner's Elbow" (occupational trauma). The critical clinical decision is distinguishing Septic (Infected) Bursitis from Aseptic (Traumatic/Inflammatory) Bursitis, as management differs significantly. Key distinguishing feature: Range of Motion (ROM) is PRESERVED in bursitis (unlike Septic Arthritis, where joint movement is severely restricted). Septic bursitis is most commonly caused by Staphylococcus aureus entering through skin breaks. Aseptic bursitis is managed conservatively; Septic bursitis requires antibiotics (Flucloxacillin) and may need surgical drainage. [1,2]
Clinical Pearls
ROM is Preserved: The bursa is EXTRA-ARTICULAR (outside the joint). Elbow flexion/extension is FULL. If ROM is restricted → Think Septic Arthritis, not bursitis.
Don't Aspirate Sterile Bursae: Needling a sterile (aseptic) bursa risks introducing infection (iatrogenic septic bursitis). Only aspirate if you genuinely suspect infection or need to rule out gout.
Cellulitis = Septic: Spreading redness beyond the bursa + Fever = Septic bursitis until proven otherwise. Needs antibiotics.
Staph aureus: The most common causative organism in septic bursitis (skin flora entering via microtrauma).
Demographics
| Factor | Notes |
|---|---|
| Age | Any age, but more common in adults (Manual workers). |
| Sex | Male > Female (Occupational exposure). |
| Occupation | Plumbers, Miners, Students, Athletes (Wrestlers, Rugby players). |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Repetitive Trauma | Leaning on elbows (Pressure). |
| Direct Trauma | Fall onto elbow. |
| Skin Breaks | Lacerations, Abrasions → Entry point for bacteria. |
| Immunosuppression | Diabetes, Steroids, Renal failure, HIV → Higher septic risk. |
| Inflammatory Conditions | Gout, Rheumatoid Arthritis, Psoriasis. |
Anatomy
- The Olecranon Bursa is a superficial bursa lying between the skin and the olecranon process.
- It allows frictionless movement of skin over the bony prominence.
- It does NOT communicate with the elbow joint (Extra-articular).
Types of Bursitis
| Type | Aetiology | Features |
|---|---|---|
| Aseptic (Non-Infected) | Repetitive friction/trauma, Gout, RA, Idiopathic. | Painless/Mild swelling, No systemic features. |
| Septic (Infected) | Bacterial infection (S. aureus, Strep). | Painful, Hot, Red, Fever, Cellulitis. |
| Condition | Key Features |
|---|---|
| Olecranon Bursitis | Swelling over tip of elbow. FULL ROM. Bursal swelling. |
| Septic Arthritis (Elbow) | Fever, SEVERE pain, RESTRICTED ROM (Especially supination/pronation). Hot, swollen joint. |
| Gout / Pseudogout | Crystal arthropathy. May affect bursae. Urate crystals on aspirate. |
| Rheumatoid Nodule | Firm nodule near olecranon in RA patients. Not fluctuant. |
| Posterior Dislocation | Following trauma. Obvious deformity. Abnormal X-ray. |
| Fracture | Trauma history. Point tenderness. X-ray confirms. |
Aseptic Bursitis
| Feature | Notes |
|---|---|
| Swelling | "Goose-egg" swelling over tip of elbow. Fluctuant (Fluid-filled). |
| Pain | Mild or None. |
| Skin | Normal colour, No warmth. |
| Systemic | No fever. Well patient. |
| ROM | FULL elbow extension/flexion. |
Septic Bursitis
| Feature | Notes |
|---|---|
| Swelling | Tense, Very tender. |
| Pain | Moderate to Severe. |
| Skin | Hot, Erythematous. Cellulitis spreading up arm. May have entry wound. |
| Systemic | Fever, Malaise, Tachycardia (Signs of sepsis). |
| ROM | Still usually FULL (Bursa is extra-articular). |
Important Clinical Signs
Aspiration (When Indicated)
| Test | Aseptic | Septic |
|---|---|---|
| Appearance | Straw-coloured, Clear. | Turbid, Purulent (Pus). |
| WBC Count | Low (less than 1000/mm³). | High (>10,000-50,000/mm³). |
| Gram Stain | Negative. | May show organisms (S. aureus). |
| Culture | Negative. | Positive (S. aureus most common). |
| Crystals | May show Urate (Gout) or Calcium Pyrophosphate (CPPD). | Absent (Unless underlying gout). |
When to Aspirate
| Indication | Rationale |
|---|---|
| Suspected Septic Bursitis | Confirm infection, Identify organism, Guide antibiotic therapy. |
| Suspected Crystal Arthropathy | Identify urate/CPPD crystals. |
| Therapeutic Drainage | Large, tense, painful collection. |
When NOT to Aspirate
- Aseptic Bursitis (Obviously Traumatic): Risk of introducing infection outweighs benefit.
- Minor Swelling with No Red Flags: Observe only.
Blood Tests
- FBC, CRP: Elevated WCC and CRP suggest infection.
- Blood Cultures: If systemically unwell.
Imaging
- X-Ray Elbow: Rule out fracture, Osteomyelitis. May show soft tissue swelling.
- Ultrasound: Can confirm fluid collection, Guide aspiration.
Management Algorithm
OLECRANON BURSITIS PRESENTATION
(Swelling over tip of elbow)
↓
CLINICAL ASSESSMENT
- Is there Cellulitis, Fever, or Systemic Toxicity?
- Is ROM preserved?
- Is there a skin break / entry wound?
↓
DIFFERENTIATE TYPE
┌────────────────┴────────────────┐
ASEPTIC (Traumatic/Inflammatory) SEPTIC (Infected)
↓ ↓
CONSERVATIVE MANAGEMENT ANTIBIOTIC THERAPY
Aseptic Bursitis (Non-Infected)
| Treatment | Notes |
|---|---|
| RICE Protocol | Rest, Ice, Compression, Elevation. |
| Elbow Pad/Protection | Avoid further pressure/trauma. |
| NSAIDs | Ibuprofen for pain/inflammation (Short course). |
| Avoid Aspiration | Unless diagnostic uncertainty or very large/symptomatic. |
| Time | Resolution takes weeks-months. |
| Steroid Injection? | Controversial. Risk of skin atrophy and introducing infection. Generally avoided. |
Septic Bursitis
| Severity | Treatment |
|---|---|
| Mild/Moderate (No systemic sepsis, Localised cellulitis) | Oral Antibiotics: Flucloxacillin 500mg-1g QDS for 7-14 days. (Clarithromycin if Penicillin allergic). |
| Review in 24-48 hours. | |
| Severe (Systemic sepsis, Extensive cellulitis, Immunocompromised) | Admit for IV Antibiotics: IV Flucloxacillin. |
| Aspiration: Confirm organism. Send for MCS. | |
| Serial Aspirations or Drainage: May be needed. | |
| Abscess / Refractory | Surgical Drainage / Bursectomy. |
Surgical Management
- Bursectomy: Excision of the bursa. Reserved for:
- Chronic recurrent bursitis.
- Failed conservative management.
- Persistent septic bursitis despite drainage and antibiotics.
| Complication | Notes |
|---|---|
| Recurrence | Common in aseptic bursitis if ongoing trauma. |
| Chronic Sinus/Fistula | Draining tract. Usually if aspirated inappropriately or surgical wound. |
| Septic Arthritis | Rare spread of infection to elbow joint. |
| Chronic Calcified Bursitis | Persistent firm lump. May need excision. |
| Osteomyelitis | Rare extension of infection to olecranon bone. |
- Aseptic Bursitis: Excellent prognosis. Resolves with conservative management over weeks-months.
- Septic Bursitis: Good prognosis if treated promptly with antibiotics. Delayed treatment → Worse outcomes.
- Recurrence: Common if precipitating factors (Repetitive trauma/pressure) not addressed.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Olecranon Bursitis | NICE CKS (2020) | Antibiotic choice, Conservative management. |
| Soft Tissue Infections | BASHH / PHE | Flucloxacillin first-line for Staph aureus. |
What is Olecranon Bursitis?
There is a small cushioning sac (bursa) at the tip of your elbow that protects the bone. Sometimes this sac fills with fluid and swells up – like a water balloon on your elbow.
What caused it?
Usually, it's from leaning on your elbows too much (on a desk, car door, etc.) which irritates the sac. Sometimes a small cut or graze lets germs in and it becomes infected.
Will you drain it?
If it's not infected, we usually don't drain it. Sticking a needle in risks introducing germs. It will gradually absorb on its own if you stop pressing on it.
How do I know if it's infected?
If the skin around it turns red and hot, starts spreading up your arm, or you feel unwell with a fever – come back immediately. You would need antibiotics.
How long will it take to go away?
It can take weeks or even months to fully settle. Wearing an elbow pad and avoiding pressure on it helps.
Primary Sources
- Baumbach SF, et al. Olecranon bursitis: management and outcome. Arch Orthop Trauma Surg. 2014;134(3):315-22. PMID: 24362295.
- Truong J, et al. Olecranon Bursitis. StatPearls. 2023. PMID: 32119339.
Common Exam Questions
- Key Exam Finding: "What differentiates Bursitis from Septic Arthritis?"
- Answer: Range of Motion – Preserved in Bursitis (Extra-articular), Restricted in Septic Arthritis.
- Organism: "Most common cause of Septic Olecranon Bursitis?"
- Answer: Staphylococcus aureus.
- Management: "First-line antibiotic for Septic Bursitis?"
- Answer: Flucloxacillin (Anti-staphylococcal).
- Risk of Aspiration: "Why avoid aspirating aseptic bursitis?"
- Answer: Risk of introducing infection (Iatrogenic septic bursitis).
Viva Points
- Gout in Bursitis: Gout can present as olecranon bursitis. Look for tophi elsewhere. Aspirate shows urate crystals.
- History Clue: Ask about occupation (Plumber, Student, Desk worker) and hobbies (Leaning on elbows).
- Cellulitis is Key: Spreading erythema beyond the bursa = Treat as Septic.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.