Diagnostic needle aspiration in olecranon bursitis may be indicated to define the underlying cause.
Date First Published:
March 1, 2000
Last Updated:
February 5, 2004
Report by:
Vince Choudaray, Specialist Registrar (Manchester Royal Infirmary)
Search checked by:
Katrina Herren, Manchester Royal Infirmary
Three-Part Question:
In [adults with a clinical diagnosis of olecranon bursitis] does [diagnostic aspiration of the bursa] lead to [better diagnosis and outcome]?
Clinical Scenario:
A 45 year old labourer presents to the Emergency Department with a one day history of pain and swelling over his right elbow. Examination reveals a generally well, apyrexial man with a swollen, warm right olecranon bursa with overlying redness. You wonder whether it is necessary to aspirate and analyse bursal fluid to diagnose an treat this patient.
Search Strategy:
Medline 1966-11/03 using the OVID interface.
Search Details:
[exp elbow OR exp elbow joint OR olecranon$.mp] AND [bursa$.mp OR exp bursa,synovial OR exp bursitis OR bursitis.mp] LIMIT to human AND English language AND abstracts.
Outcome:
136 papers found of which 3 were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparison of Nonseptic and Septic Bursitis. Further Observations on the Treatment of Septic Bursitis. Ho G Jr, Tice AD. 1979, USA | 30 consecutive patients with olecranon (25) or pre patellar (5) bursitis 20 non-septic and 10 septic |
Survey | Predominant white cell type | mononuclear vs polymorphonuclear | Small numbers No statistical analysis |
| White cell count | 1,523 vs 108,630 per mm³ | ||||
| Simple tests for septic bursitis: comparative study. Stell IM, Gransden WR. 1998 UK | 36 patients with olecranon (28) or pre patellar (8) bursitis 19 non-septic and 17 septic |
Diagnostic | Median white cell counts | Sensitivity 94%, specificity 79% at > 2 x 109 / l | Small numbers Gold standard was expert opinion |
| Culture in liquid medium | Sensitivity 100%, specificity 89% | ||||
| Management of acute bursitis: outcome study of a structured approach Stell IM 1999 UK | 47 patients with bursitis. 32 had olecranon bursitis | Observational Cohort | Number of olecranon patients with sepsis on culture | 15/32 (47%) | Small study with fairly wide confidence intervals. All patients were aspirated - not know if it was possible to correlate microbiological findings with presenting features. |
Author Commentary:
While two studies addressed the diagnostic question alone, no comparitive studies could be found regarding the usefulness of diagnostic aspiration in improving outcome.
The papers do suggest that a large number of bursitis patient have definable infection; though the sensitivity of white cell analysis is just too low for use as a SnOut. Liquid culture, while absolutely sensitive, takes so long that blind treatment will usually be necessary until the result is available.
Our clinical practice does suggest that some patients have very few signs of infection though there are no papers that correlate clinical findings with microbiological diagnosis - which would be useful.
The papers do suggest that a large number of bursitis patient have definable infection; though the sensitivity of white cell analysis is just too low for use as a SnOut. Liquid culture, while absolutely sensitive, takes so long that blind treatment will usually be necessary until the result is available.
Our clinical practice does suggest that some patients have very few signs of infection though there are no papers that correlate clinical findings with microbiological diagnosis - which would be useful.
Bottom Line:
If septic bursitis is suspected then antibiotics (anti-staphylococcal) should be started. Initial aspiration may be useful in determining whether sepsis is the underlying cause and in defining when to stop treatment.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Ho G Jr, Tice AD.. Comparison of Nonseptic and Septic Bursitis. Further Observations on the Treatment of Septic Bursitis.
- Stell IM, Gransden WR.. Simple tests for septic bursitis: comparative study.
- Stell IM. Management of acute bursitis: outcome study of a structured approach