Elbow Case Study 1: Olecranon Bursitis

Anatomy & Pathology

A Bursa is a small sac that contains fluid – fluid is similar to fluid in the oint –
synovial fluid. There are several Bursae in the body – one just over the olecranon –
bursa help make movements smooth between bones which stick out and the nearby
overlying skin.

The bursa is located quite superficially on the extensor side of the olecranonon – it is
easily irritated and inflamed. Bursitis may arise from trauma – from falls or direct
blows. It ay also arise from prolonged irritation – and it may be assosciated wth
systemic inflammatory conditions such as Rhematoid Arthritis and gout. Furthermore
infection ay develop in the bursa – this is known as septic bursitis. In bursitis – the
bursa becomes inflamed – it swells and extra fluid is made.

The location of the ulnar nerve is significant. It can become entrapped by spreading
inflammation around the olecranon.

Subjective Examination
Where\What : pain at olecranon and down posterior arm

When: 6 weeks ago

How: ask – has trauma been involved ?

0-10 rating: intermittent and increasing – nb most bursitis evidences no pain !

24 hour cycle: n/a

Better for: rest

Worse for: contact – ask what is it like putting on a shirt – this will give you an idea
of the severity of the patients symptoms

Type of pain: diffuse pain

Past Medical History/ General History: none – but ask do they suffered from gout
Or rheumatoid arthritis

Red Flags and general concerns: the pain the patient experiences is unusual – has
there been trauma is the wound going septic – is there nerve entrapment. Ask the
patient if they are experiencing fevers chills or sweats – these would be an indication
of infection

SH: still caring for young daughter

DH: non – ask about DMARDS and colchicine – (an anti-gout drug)

Patients main outcome: this could be something like returning to work

Objective Examination

Working Hypothesis:
We can approach the patient expecting to confirm Bursitis – the bigger questions are
has there been any trauma , has the bursitis become septic and is there any nerve
entrapment.

Advice & Consent: Explain the examination – counsel about short term
side effects – and obtain consent.

General Observations: Watch the way the patient carrys their elbow –
watch the way they take off any clothes.

Acute Observations:
Skin colour – lacerations and bruising may be a sign of trauma – while redness and
heat may be a sign of infection.

Swelling – up to 6cm in diameter

Posture – depends on how they are carrying their affected elbow – are they protecting
it.

Muscle Bulk – may be some decrease in bulk of elbow flexors – reduced elbow
flexion can be anticipated

Active Tests: Position the patient sitting up in supine – or sitting across the
corner of the bed.
Flexion - can be painful – streches bursa at end – is diffuse pain assosciated with
ulnar nerve ?

Extension
Pronation
Supination

Passive Tests: Check joint integrity – if there has been trauma the end feel
might be different – residue of a fracture ?

Flexion – can painful – streches bursa

Extension
Pronation
Supination

Resisted Tests: Any weakness may be due to inactivity

Flexion – painful ? – as above
Extension
Pronation
Supination

Special Tests:
Varus and Valgus – test integrity of joint ( trauma )
Tinels sign – tap groove for ulnar nerve – tingling => neuropathy
Reverse Phalens test – hold hands in prayer position for 1 minute – tingling =>
neuropathy

Functional Tests:
Ask patient to put jumper on and off – watch to see how they might avoid and react to the
sensation of the bursa being touched by clothing.

Palpation:
Expect equisite tenderness if infected – less painful if simply chronic swelling
Percuss surrounding bones where appropriate seeking a fracture – displace bones if
painful reaction to percussion. This is a further fracture test.

Measurements:
Measure the size of the bursa. Compare this with other side. Measure pain at flexion.
Advice & Possible Treatment:
Mild symptoms – NSAIDs
Wear an elbow pad and avoid hyperflexion

But strong symptoms – septic ? check with aspiration and tests and treat with oral
antbiotics. If not septic try a compression bandage of 8cm foam and an elastic wrap ->
see inside a week – no response ? then steroids may be considered