The olecranon bursa lies immediately below the skin. This superficial location increases the risk of skin damage and infection from corticosteroid injection, which is usually avoided in superficial bursae, except sometimes for bursitis caused by crystals (eg, gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more ) or rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically... read more .
(See also Bursitis Bursitis Bursitis is acute or chronic inflammation of a bursa. The cause is usually unknown, but trauma, repetitive or acute, may contribute, as may infection and crystal-induced disease. Symptoms include... read more .)
Aspiration of effusion to determine cause of bursitis
Rarely for injection of corticosteroid to treat inflammation
Olecranon bursal puncture is usually done diagnostically (eg, to diagnose septic or crystal-induced bursitis). Because the olecranon bursa is the most common site of septic bursitis, olecranon effusion should be sent to the laboratory for cell count, Gram stain, culture, and sensitivity tests.
Corticosteroid injection is rarely necessary in the olecranon bursa (based on an increased risk of infection and skin atrophy and a paucity of data showing improved long-term outcomes). Therapeutic injection should be done only if all of the following criteria are satisfied:
Infection has been excluded by bursal fluid analysis.
Bursal fluid reaccumulates.
Symptoms are not relieved by local measures such as ice, elevation, elastic bandage, and nonsteroidal anti-inflammatory drugs.
When needed, bursal injection therapy provides rapid relief, which can be particularly beneficial for large or painful effusions.
Overlying cellulitis or skin ulcer, bacteremia, adjacent prosthetic joint
Hypersensitivity to an injected substance
For corticosteroid injection, suspected septic bursitis
Poorly controlled diabetes: Any benefit of corticosteroids is weighed against risk of worsening glycemic control.
Previous corticosteroid injection into same site: Many experts advise waiting 3 to 4 months between injections and not exceeding a lifetime total of 4 injections.
Complications are uncommon and include
Subcutaneous fat atrophy, skin atrophy and sinus tracts, temporary skin depigmentation, and infection due to superficial (< 0.5 cm deep) corticosteroid injection
Painful local reaction (sometimes called steroid flare) occurring within a few hours of depot corticosteroid injection and usually lasting ≤ 48 hours (probably irritation due to crystals in the injection vehicle)
In diabetic patients, hyperglycemia that may persist for weeks after a depot corticosteroid injection
Antiseptic solution (eg, chlorhexidine, povidone iodine, isopropyl alcohol)
Sterile gauze, sterile gloves, sterile adhesive bandage
20-mL syringe with 18- to 20-gauge needle for fluid withdrawal
Needle insertion site anesthesia (eg, topical freezing spray and/or injectable 1% lidocaine without epinephrine, in a 3-mL syringe)
Optional: For therapeutic injection, 5- to 10-mL syringe with 2 to 3 mL 1% lidocaine without epinephrine, rarely with injectable depot corticosteroid (eg, triamcinolone acetonide, 20 mg)
For diagnostic aspiration, appropriate tubes for specimen collection, including blood culture bottles
Having an assistant is helpful.
For bursal injection therapy, local anesthetic and depot corticosteroid can be mixed in a single syringe (the anesthetic eliminates the pain of the corticosteroid).
Corticosteroid injection is rarely necessary in the olecranon bursa (based on an increased risk of infection and skin atrophy and a paucity of data showing improved long-term outcomes).
Septic bursitis cannot be ruled out by the initial gross and microscopic examination of the aspirated effusion; infected fluids (even from Staphylococcus aureus, the most common organism) tend to show a minimal fluid leukocytosis.
If the history or physical examination suggests septic bursitis, withhold corticosteroid injection. Septic bursitis requires drainage or sometimes bursal excision in addition to systemic antibiotics.
Immediate analgesia after injection of local anesthetic helps confirm correct needle placement and that the olecranon bursa is the source of pain.
The olecranon bursa overlies the tip of the olecranon process and is superficial.
Seat or partially recline the patient, with the arm comfortably flexed about 90° at the elbow and resting on a bedside table. The patient may also be supine on an examination table with the elbow flexed.
To avoid vasovagal episodes, avert the patient's head and orient your work area so that the patient does not see the needles.
Step-by-Step Description of Procedure
Do the procedure using sterile technique.
Prepare the site
Identify the bursa's point of maximum fullness and mark it on the skin for needle entry.
Prepare the area with antiseptic solution.
Apply sterile drapes that widely expose the needle insertion site and olecranon.
Spray freezing spray at the needle insertion site until it just blanches and/or inject a skin wheal of local anesthetic (eg, ≤ 1 mL).
Puncture the bursa
Wear sterile gloves.
Insert the needle (attached to the aspirating syringe) into the skin at the site of maximum fullness.
Advance the needle into the center of the bursa. Gently pull back on the plunger as you advance the needle tip to the center of the swelling.
Fluid will enter the syringe when the bursa is entered.
Drain all fluid from the bursa. Use your fingertips to apply gentle external pressure to the bursal sac to milk the fluid toward the needle tip.
If injecting the bursa, stabilize the needle hub with your hand and switch syringes. If the needle is on too tight, hold the hub of the needle with a hemostat.
Inject any drugs and withdraw the needle.
Apply an adhesive bandage or sterile dressing.
Transfer bursal effusion samples to tubes and other transport media for synovial fluid analysis Synovial fluid examination Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures, Paget disease of bone, tumors), muscles or other extra-articular... read more . Inspect the fluid for blood and fat.
A protective elastic elbow brace or compression bandage may prevent reaccumulation of fluid.
Prescribe limited activity, ice, elevation, and oral nonsteroidal anti-inflammatory drugs (NSAIDs) until pain subsides.
Instruct the patient to return for reassessment to exclude infection if pain is continuously and progressively increasing after several hours or persists for > 48 hours.
Warnings and Common Errors
Do not inject corticosteroids against resistance; if there is resistance, slightly withdraw the needle.
Tips and Tricks
Consider doing ultrasonography if there is no obvious large effusion.
When inspecting bursal fluid, consider the following: The blood due to a traumatic needle insertion tends to be nonuniformly bloody and tends to clot.