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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > Musculoskeletal Procedures > 71 – Aspiration and Injection of Olecranon Bursitis 71 Aspiration and Injection of Olecranon Bursitis The olecranon bursa is situated between the tip of the olecranon and the skin, and it is best examined with the elbow fully extended. This location over the elbow frequently is subjected to repetitive friction and trauma. The bursa most often becomes inflamed from activities or occupations that involve chronic leaning on the elbow, or inflammation may be produced from a single injury. Inflammatory olecranon bursitis may result from gout, rheumatoid arthritis, or calcium pyrophosphate deposition disease. Uremic patients undergoing hemodialysis may also experience inflammatory olecranon bursitis. Olecranon bursitis is diagnosed by the appearance of a fluctuant swelling over the elbow. The bursa frequently becomes infected, and the presence of erythema, warmth, and tenderness should alert the practitioner to the possibility of septic bursitis. However, many positive cultures can be obtained from distended bursae that do not exhibit the classic physical findings of infection. Some physicians advocate testing to exclude infection before injection of corticosteroids in the olecranon bursa, especially if turbid fluid is present on aspiration. Chronic inflammatory reactions often produce a nontender, rubbery bursa. Villous thickening in chronic bursitis can produce multiple, small nodules that can be mistaken for bone fragments. Drainage of chronic bursitis often is followed by reaccumulation. Fortunately, the fluid tends to resolve over several months. Chronically painful bursae may require total excision for symptom resolution. After episodic injury, the bursa fills with blood or clear fluid to produce a tender, painful swelling over the elbow. Aspiration of fluid followed by application of a support wrap over the elbow may be successful in resolving an acute bursitis. Acute bursitis usually spontaneously resolves over a few weeks. If infection develops after an acute injury, treatment consists of antibiotics (usually cephalosporins or penicillinase-resistant penicillins such as dicloxacillin), moist heat, and splinting. A white blood cell count of 10,000 cells/mm3 is consistent with infectious bursitis, and traumatic bursitis that is not infected usually has a count of less than 1000 cells/mm3. Repeated aspiration or occasionally incision and drainage may be required to resolve the condition. P.575
INDICATIONS

  • Symptomatic or cosmetic concerns over distention of the olecranon bursa
  • Suspicion of septic bursitis of the olecranon bursa

RELATIVE CONTRAINDICATIONS

  • Uncooperative patient
  • Coagulopathy or bleeding diathesis

P.576
PROCEDURE Olecranon bursitis is depicted.

(1) Olecranon bursitis.

The elbow is flexed to 90 degrees for the aspiration. Most physicians prefer a lateral approach to avoid the ulnar nerve. A 20- to 25-gauge, 1¼-inch needle is inserted, and fluid is removed. Some physicians recommend performance of a Gram stain, culture and sensitivity tests, white blood cell count and differential count, and crystal analysis on all fluid before steroids are administered.

(2) Have the patient flex his or her elbow 90 degrees, and insert a 20- to 25-gauge, 1¼-inch needle laterally to remove fluid.

PITFALL: Two procedures generally are needed to perform the bacteriologic studies after aspiration and then to inject corticosteroid. The injection can be performed on the same date or at a later visit. Avoid injecting steroid into a bursa with a subacute infection. P.577
After the injection, the patient can receive nonsteroidal antiinflammatory drugs (NSAIDs), immobilization, and compression dressing. If corticosteroid is administered, 0.5 mL of Celestone and 2.5 mL of 1% lidocaine can be administered.

(3) Patients can receive NSAIDs, immobilization, and compression dressing after aspiration.

Acutely occurring bursitis that is infected may benefit from an indwelling catheter placed in the bursa while intravenous, intramuscular, or oral antibiotics are administered.

(4) For acutely occurring bursitis that is infected, place an indwelling catheter in the bursa while intravenous, intramuscular, or oral antibiotics are administered.

P.578
CODING INFORMATION

CPT® Code Description 2002 Average 50th Percentile Fee
20605* Aspiration and injection of intermediate joint (olecranon) bursa $97
CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING Consult the ordering information that appears in Chapter 65. Needles, syringes, and corticosteroid preparations may be ordered from surgical supply houses or local pharmacies. A suggested tray for performing soft tissue aspirations and injections is listed in Appendix D. Skin preparation recommendations appear in Appendix H. BIBLIOGRAPHY Baker CL, Jones GL. Arthroscopy of the elbow. Am J Sports Med 1999;27:251–264. Beetham WP, Polley HF, Slocumb CH, et al. Physical examination of the joints. Philadelphia: WB Saunders, 1965:44–48. Biundo JJ. Regional rheumatic pain syndromes. In: Klippel JH, Weyand CM, Wortmann RL, eds. Primer on the rheumatic diseases, 11th ed. Atlanta: Arthritis Foundation, 1997:136–148. Buttaravoli P, Stair T. Minor emergencies: splinters to fractures. St. Louis: Mosby, 2000:265–266. Kraay MJ. The painful elbow: causes to consider. Hosp Med 1994;30:25–34. Matfin G, Luchsinger A, Martinez J, et al. An inflamed elbow after an insect sting. Hosp Pract 1998;33:41–44. Mercier LR, Pettid FJ, Tamisiea DF, et al. Practical orthopedics, 4th ed. St. Louis: Mosby, 1991:91. Owen DS, Irby R. Intra-articular and soft-tissue aspiration and injection. Clin Rheumatol Pract 1986;Mar-May:52–63. Villarin LA, Belk KE, Freid R. Emergency department evaluation and treatment of elbow and forearm injuries. Emerg Med Clin North Am 1999;17:843–858. Wilson FC, Lin PP. General orthopaedics. New York: McGraw-Hill, 1997:424.

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