Aspiration of the olecranon bursa is done for diagnostic purposes (eg, to diagnose septic bursitis, gout). Injection of corticosteroids into the olecranon bursa is typically avoided but may be done selectively (eg, in patients with recurrent and painful, large effusions).
The olecranon bursa lies immediately below the skin. This superficial location increases the risk of skin damage, fluid leakage, and infection from corticosteroid injection. Thus, injection of corticosteroids is usually avoided for superficial bursae. Occasionally, corticosteroid injection is used to treat refractory or painful bursitis due to crystals (eg, gout) or rheumatoid arthritis, or if there is a significant recurrent noninfectious post-traumatic bursal effusion.
(See also Bursitis.)
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Indications for Aspirating or Injecting an Olecranon Bursa
Aspiration of bursal effusion to determine cause of bursitis
Rarely, injection of corticosteroid for persistent or recurrent bursitis
Olecranon bursa aspiration is usually done for diagnosis (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 and differential, crystal analysis, Gram stain, culture, and sensitivity tests.
Corticosteroid injection is occasionally necessary in the olecranon bursa. 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 or orthosis wear, and nonsteroidal anti-inflammatory drugs (if not contraindicated).
When needed, bursal injection may provide rapid relief, which can be particularly beneficial for large or painful effusions.
Contraindications to Aspirating or Injecting an Olecranon Bursa
Absolute contraindications
Hypersensitivity to an injected substance
For corticosteroid injection, suspected septic bursitis
Insertion of a needle directly through infected skin should be avoided; however, if there is clinical suspicion for septic bursitis, the bursa should be aspirated, ideally before giving systemic antibiotics.
Relative contraindications
Poorly controlled diabetes: Any benefit of corticosteroids is weighed against risk of worsening glycemic control and risk of infection.
Recent (ie, within the last 3 months) corticosteroid injection into same site (although no evidence has evaluated this practice)
Coagulopathy is not a contraindication (1).
Complications of Aspirating or Injecting an Olecranon Bursa
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 thought to result from a chemical synovitis in response to the crystals in the corticosteroid solution (sometimes called postinjection flare) occurring within a few hours of depot corticosteroid injection and usually lasting ≤ 48 hours
In diabetic patients, hyperglycemia after a depot corticosteroid injection
Equipment for Aspirating or Injecting an Olecranon Bursa
Sterile gauze, gloves, adhesive bandage
20-mL syringe with 18- to 20-gauge needle for fluid withdrawal
Hemostat, if switching of syringe while leaving the needle inserted after aspiration is anticipated
Some 3-, 5-, and 10-mL syringes
For diagnostic aspiration, appropriate tubes for specimen collection, including blood culture bottles
Having an assistant is helpful.
Additional Considerations for Aspirating or Injecting an Olecranon Bursa
For bursal injection, local anesthetic and depot corticosteroid can be mixed in a single syringe. Adding the anesthetic helps confirm good needle placement when injection immediately relieves pain. Adding anesthetic also may decrease the risk of the corticosteroid causing subcutaneous fat atrophy and the risk of postinjection flare.
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 (although there is generally a high percentage of neutrophils). 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.
Surgical excision of the bursa may be necessary for recalcitrant or recurrent sterile effusions or unresolving infections.
Relevant Anatomy for Aspirating or Injecting an Olecranon Bursa
The olecranon bursa overlies the tip of the olecranon process and is superficial.
Positioning for Aspirating or Injecting an Olecranon Bursa
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 Aspirating or Injecting an Olecranon Bursa
Prepare the site
Identify the bursa's point of maximum fullness and aspirate at the base (bottom) of the distended bursa, trying to avoid areas of skin thinning to limit likelihood of post-aspiration leakage.
Prepare the area with antiseptic solution.
Spray freezing solution 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 gloves.
Insert the needle (attached to the aspirating syringe) into the skin at the base of the bursa.
Advance the needle into the center of the bursa. Gently pull back on the plunger intermittently 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 fluid analysis. Inspect the fluid for blood and fat.
Aftercare for Aspirating or Injecting an Olecranon Bursa
A protective elastic elbow brace or compression bandage may prevent reaccumulation of fluid.
Prescribe limited activity, ice, elevation, and, if not contraindicated, 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 for Aspirating or Injecting an Olecranon Bursa
Do not inject corticosteroids against resistance; if there is resistance, slightly withdraw the needle.
Tips and Tricks for Aspirating or Injecting an Olecranon Bursa
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. Nontraumatic fluid should be evaluated by polarized light microscopy for the presence of crystals.
Reference
1. Yui JC, Preskill C, Greenlund LS: Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 92(8):1223–1226, 2017. doi: 10.1016/j.mayocp.2017.04.007
