Elbow (Olecranon) Bursitis
What is it?
Elbow bursitis occurs in the olecranon bursa; the olecranon bursa is a fluid-filled sac located at the elbow’s boney tip (the olecranon).
Olecranon bursitis is the most common bursitis around the elbow. A bursa is a soft tissue “cushion” between bone and tendons, ligaments or the skin. The olecranon is part of the ulna bone of the forearm that makes the ‘point of the elbow’. Many bursae are located throughout the body that acts as cushions between bones and soft tissues, such as skin. They contain a small amount of lubricating fluid that allows the soft tissues to move freely over the underlying bone.
Normally, the olecranon bursa is flat. If it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.
What causes it?
Elbow bursitis can occur for several reasons.
Trauma. A hard blow to the tip of the elbow can cause the bursa to produce excess fluid and swell.
Prolonged Pressure. Leaning on the tip of the elbow for long periods on hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this type of bursitis develops over several months.
People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who crawl on their knees in tight spaces and lean on their elbows. Certain athletic activities may also prompt the development of olecranon bursitis, such as long holds of the plank position.
Infection. If an injury at the tip of the elbow breaks the skin, such as an insect bite, scrape, or puncture wound, bacteria may get inside the bursa sac and cause an infection. The infected bursa produces fluid, redness, swelling, and pain. If the infection goes untreated, the fluid may turn to pus. Occasionally, the bursa sac may become infected without an apparent injury to the skin.
Medical Conditions. Certain conditions, such as rheumatoid arthritis and gout, are associated with elbow bursitis.
To summarise, most cases are caused by inflammation. The cause of this is not always known, but it may be associated with other conditions such as rheumatoid arthritis and gout. Occasionally the swelling may be caused by infection. In these cases, there may be some other symptoms, such as fever.
How is it treated?
If Prof Imam suspects that bursitis is due to an infection, he may recommend aspirating (removing the fluid from) the bursa with a needle. This is commonly performed in clinics or in the radiology department.
Fluid removal helps relieve symptoms and gives your doctor a sample that can be looked at in a laboratory to identify any bacteria. This also lets your doctor know if a specific antibiotic is needed to fight the infection.
Your doctor may prescribe antibiotics before the exact type of infection is identified.
This is done to prevent the infection from progressing. The antibiotic that your doctor prescribes at this point will treat a number of possible infections.
If the bursitis is not from an infection, there are several management options.
⦁ Elbow pads. An elbow pad may be used to cushion your elbow.
Examples of elbow pads:
⦁ Activity changes. Avoid activities that cause direct pressure to your swollen elbow.
⦁ Medications. Oral medications such as Naproxen or Ibuprofen or other anti-inflammatories may be used to reduce swelling and relieve your symptoms.
If swelling and pain do not respond to these measures after 3 to 6 weeks, Prof Imam may recommend removing fluid from the bursa and injecting a medication into the bursa. The medication is an anti-inflammatory drug that is stronger than the medication that can be taken by mouth.
In some patients, corticosteroid injections work well to relieve pain and swelling. However, some patients do not have any relief of symptoms with corticosteroid injections.
The first line of treatment is oral anti-inflammatory medication. If an infection is suspected, a broad-spectrum antibiotic may be prescribed after a specimen has been obtained by aspiration from the bursa to send for microbiological investigation.
The needle should not be passed directly into the bursa over the ‘point’ of the elbow as this may lead to a persistent tract into the bursa. The needle should be passed obliquely into the bursa from the surrounding healthy tissue.
If these measures fail, surgery may be required.
The bursa can be removed through an open cut technique or through a ‘keyhole’ endoscopic technique. The open cut technique requires a longer cut in the skin and is associated with problems with wound healing.
Surgery for an infected bursa
If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery to remove the entire bursa may be needed. This surgery may be combined with further use of oral or intravenous antibiotics. The bursa usually grows back as a non-inflamed, normally functioning bursa over a period of several months.
Surgery for the noninfected bursa
If elbow bursitis is not a result of infection, surgery may still be recommended if nonsurgical treatments do not work. In this case, surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structures.
The hospital or surgery center will contact you ahead of time to provide specific details about your procedure. Make sure to follow the instructions on when to arrive and especially on when to stop eating or drinking prior to your surgery.
Before the operation, a member of the anaesthesia staff will talk with you about anaesthesia options. The procedure is usually performed using general anaesthesia, meaning you are put to sleep.
Regional nerve block injections that numb just your elbow area are rarely used in elbows’ surgery because the numbing effect can last for a few hours after the procedure is completed. Although the numbing effect can help with managing pain, it prevents your surgeon from completing a careful nerve examination in the recovery room to make sure that the nerves that travel down your arm are functioning well.
If necessary for pain control, a regional anaesthetic may be provided in the recovery room after your surgeon completes the nerve examination.
What can I expect if I have surgery?
The procedure is usually carried out under a general anaesthetic. In most cases, it can be performed as a day case with no overnight hospital stay.
You can expect to be discharged wearing a bandage and a sling for comfort with tablets for pain control.
The wound will typically take ten days to heal and should be kept clean and dry for this time.
Bruising around the elbow may track under the skin towards the fingers.
Most people can return to driving within two weeks of surgery.
What are the risks of surgery?
The main risks of surgery are wound healing problems and numbness around the elbow with the open-cut technique.
There is a risk of wound infection with any method. There is a risk of the bursa coming back. This risk is increased if there is a history of rheumatoid arthritis or gout.
There is a very small risk of injury to the ulnar nerve with the’ keyhole’ technique.
What is the recovery after surgery?
Prof Imam might apply a splint to your arm after the procedure to protect your skin. In most cases, casts or prolonged immobilization are not necessary.
Although formal physiotherapy after surgery is not usually needed, Prof Imam or a team member will recommend specific exercises to improve your range of motion. These are typically permitted within a few days of the surgery.
Your skin should be well healed within 12 to 16 days after the surgery, and after 3 to 4 weeks, Prof Imam may allow you to use your elbow fully. Your elbow may need to be padded or protected for several months to prevent reinjury.