9.11 Bursitis

agk’s Library of Common Simple Emergencies

Presentation

Following minimal trauma or repetitive motion, a nonarticular synovial sac, or bursa, protecting a tendon or prominent bone becomes swollen, tender, and inflamed. Because there is no joint involved, there is no decreased range of motion, but, if the tendon sheath is involved, there may be some stiffness and pain with motion.

What to do:

• Obtain a detailed history of the injury or precipitating activity document a.thorough physical examination, and rule out a joint effusion (see below).
• Prepare the skin with alcohol and antiseptic solution and 1% lidocaine anesthetic. Puncture the swollen bursa with a #18 or #20 needle, using aseptic technique, and withdraw some fluid to drain the effusion and rule out a bacterial infection.
• Examine a Gram stain of the effusion and send a sample for leukocyte count and culture. If there is any sign of a bacterial infection, prescribe appropriate oral antibiotics. (Bacterial infections tend to be gram-positive cocci and respond well to cephalexin or dicloxacillin 500mg tid x 7d.)
• Bacterial infections may also respond to direct injection of antibiotics. Severe inflammatory bursitis may require injection of local anesthetics (lidocaine, bupivacaine) and corticosteroids like methylprednisolone (Solu-Medrol) 40mg or betamethasone (Celestone Soluspan) 0.25-0.5mg.
• Construct,a splint and instruct the patient in rest, elevation, and ice packing. Prescribe nonsteroidal anti- inflammatory medications, and arrange for followup.

Discussion

Common sites for bursitis include several bursae of the shoulder and knee, the olecranon bursa of the elbow, and the trochanteric bursa of the hip. Patients with septic bursitis, unlike those with septic arthritis, can often be safely discharged on oral antibiotics because the risk of permanent damage is much less when there is no joint involvement. Some long-acting corticosteroid preparations can produce a rebound bursitis several hours after injection, when the local anesthetic wears off, but before the corticosteroid crystals dissolve. Patients should be so informed.

Illustration

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