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April 2002
By James R. Roberts, MD
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A 60-year-old man sought medical attention in the emergency department
for painless elbow swelling that had developed gradually over the
previous week. He could not remember falling or any other precipitating
trauma. Examination revealed a painless, fluctuant, mobile, homogeneous
mass about the size of a golf ball over the olecranon. The skin
was intact; no warmth or tenderness was noted, and the joint had
full range of motion. The patient was afebrile. Radiographs revealed
no evidence of fracture, foreign body, or joint effusion. Though
his medical history documented only well-controlled hypertension
and no current anticoagulant use, the patient thought he remembered
having the same problem 15 years ago and "getting a shot for it."
Most of his afternoons, he did admit, were spent with his elbows
on a bar as he chatted with friends over a "few beers." That revelation
led one examiner to assume that the elbow mass was probably a bruise
or other trauma sustained while the patient was intoxicated and
that it should be treated with an elastic bandage and some ibuprofen.
A logical conclusion, it would seem, but the examiner was overlooking
another possibility.
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ANSWER
The actual diagnosis was an accumulation of sterile fluid in the
olecranon bursa, of which this was a classic example. Though neither
painful nor acutely inflammatory, the disorder is nevertheless referred
to as olecranon bursitis. The exact etiology remains unknown in
many cases, but generally the condition has been ascribed to minor
or repeated trauma to the elbow. Radiographs are usually obtained
because patients often conjure up some type of trauma in the history
to explain the swelling. A calcific spur on the olecranon is a common
finding but has no diagnostic or etiologic significance.
A more serious variant of olecranon bursal
fluid accumulation is septic olecranon bursitis, which is usually
caused by gram-positive bacteria such as Staphylococcus aureus.
This is easily distinguished from benign sterile fluid accumulation
by significant pain and tenderness, more diffuse swelling, and redness
and warmth of the skin over the area. It is often accompanied by
fever and leukocytosis. (Acute gouty bursitis, however, may mimic
a bursal infection.) Septic bursitis usually occurs in patients
with a predisposing factor such as diabetes or a break in the skin.
Drainage and antibiotics, occasionally by parenteral administration,
are required. A final consideration in the differential diagnosis
of this case was hematoma, which would have been likely if the patient
had been taking coumadin.
The patient would likely have returned
soon if misdiagnosed, since spontaneous resolution of benign olecranon
bursitis is unusual. The fluid needs to be aspirated with an 18-gauge
needle (left), followed by injection of a long-acting corticosteroid,
such as 40 mg methylprednisolone, via the same needle (right). Without
the steroid injection, the fluid typically reaccumulates. After
the procedure, an elastic compression bandage can be applied; usually
there is no need for analgesic or anti-inflammatory medication.
Culture and additional analysis of the aspirated fluid rarely provide
any useful information and is not standard if infection can be ruled
out on clinical grounds.
Emerg Med 34(4):55, 2002
Dr. Roberts is professor of emergency medicine at the Medical
College of Pennsylvania and chairman of the department of emergency
medicine at Mercy Catholic Medical Center in Philadelphia. He is
also a member of the Emergency Medicine editorial board.
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