What is the diagnosis?

The patient is diagnosed with Olecranon Bursitis.

Image 2. Plain radiograph of the left elbow. Case courtesy of Ian Bickle, Radiopaedia.org, rID: 86031. Annotated by author.

• Pearl: The diagnosis of olecranon bursitis is very often made by clinical diagnosis alone. Diagnostic tests can become important when considering alternative diagnoses or infection [1].

What is the mechanism of injury?

The typical mechanism of injury for olecranon bursitis is direct trauma to the elbow, which can cause inflammation and swelling of the bursa located at the tip of the elbow. Olecranon bursitis is most commonly seen in contact sports like football, rugby, and hockey, where falls and collisions are common. In other cases, olecranon bursitis can develop from repetitive pressure or friction on the elbow, such as in individuals who spend prolonged periods of time leaning on their elbows or performing activities that put pressure on the area. 

• Pearl: Some medical conditions, such as gout, rheumatoid arthritis, and infection, can also cause olecranon bursitis [1,2,3].

What physical exam findings are expected?

Although the diagnosis can usually be made on clinical history and presentation, it is important to do a thorough physical exam to exclude other etiologies. During a physical examination, a patient with olecranon bursitis typically presents with swelling and tenderness at the posterior elbow, indicating fluid accumulation within the bursa. The affected skin may exhibit erythema and warmth. The patient typically will have full range of motion of the elbow, however, in some instances they may experience a limited range of motion due to pain. 

• Pearl: It is very important to consider septic bursitis. 

Which imaging modalities can be used?

When there is a traumatic mechanism and a fracture or soft tissue injury is suspected, additional imaging studies, such as X-ray or ultrasound may be ordered.

• Pearl: If there is diagnostic uncertainty in the outpatient setting MRI could be obtained. 

Image 3. MRI of left elbow in Olecranon Bursitis. Case courtesy of Ayaz Hidayatov, Radiopaedia.org, rID: 80699

What is the management in the ED?

The treatment approach to olecranon bursitis hinges on whether the bursitis is septic or non-infectious. Acute non-infectious bursitis is typically self-limited and can be managed conservatively using rest, ice, and NSAIDs as well as the application of an elastic bandage, which may also prevent additional swelling [1]. The use of bursal aspiration can be used on a case-by-case basis while evaluating the risks and benefits of diagnostic aspiration, therapeutic relief, potential for creating a sinus tract, and avoiding iatrogenic infection [1,2,3]. They can then follow up with their PCP outpatient in 1-2 weeks. An associated fracture should be managed appropriately and followed up by orthopedics in the outpatient setting.

• Pearl: The use of intrabursal corticosteroid injections in managing olecranon bursitis is not recommended due to potential side effects such as iatrogenic infection, skin changes, muscle atrophy, and the risk of triceps rupture. Additionally, steroid injections have not been shown to be more effective than conservative management in achieving complete resolution of signs and symptoms [1,2].

When do you consult Orthopedics?

Emergent orthopedic consultation is not required in the emergency department unless there is concern for an open fracture or septic bursitis [1,2]. If there is a non-displaced closed fracture, they can follow up with orthopedics or primary care sports medicine outpatient.