Olecranon bursitis — Rapid | Doctor’s Passport

Synopsis

Distinguish non-septic olecranon bursal swelling from infection, gout, trauma and septic arthritis, sample selectively and safely, treat the cause, and escalate systemic or deep infection before function is threatened.

Olecranon bursitis produces a discrete fluctuant swelling directly over the posterior elbow; passive joint movement is often relatively comfortable unless the bursa is tense or the joint is involved.
Always separate septic from non-septic disease using warmth, erythema, skin breach, drainage, fever, immune risk and pain with passive joint movement.
First-line investigation for uncomplicated pressure-related swelling is clinical assessment; routine aspiration is unnecessary and can introduce infection.
Aspirate when infection or crystal disease is a meaningful possibility and the result will change treatment, using aseptic technique away from cellulitic skin and sending cell count, Gram stain, culture and crystals.
First-line sterile management is pressure avoidance, padding, compression when comfortable, ice and short suitable analgesia; preserve elbow movement.
Suspected septic bursitis requires prompt anti-staphylococcal antibiotics after sampling when safe, early review and escalation for systemic illness, abscess, deep extension or failure.
Do not inject corticosteroid into a hot, infected or unconfirmed bursa; routine steroid use is limited by skin atrophy, infection and recurrence risk.
Consider bursectomy or treatment of an olecranon spur only for recurrent, chronic, draining or treatment-resistant disease after the cause has been reviewed.

Key red flags

Fever, rigors, tachycardia, hypotension or confusion with posterior elbow swelling requires urgent sepsis assessment and intravenous treatment when indicated.

Spreading erythema, skin necrosis, purulent drainage, rapid reaccumulation or immune compromise supports same-day specialist review for septic bursitis or abscess.

Marked pain and restriction through passive elbow movement suggests septic arthritis rather than an isolated superficial bursa and needs urgent joint aspiration.

Trauma with inability to extend, focal bony tenderness or a palpable triceps defect requires radiographs and extensor-mechanism assessment.

Atypical firm mass, progressive night pain or non-resolving enlargement requires investigation for rheumatoid nodule, tophus or tumour.

Investigation priorities

First-line clinical compartment assessmentFirst stepFirst line

Distinguish bursal swelling from joint effusion, fracture, tendon rupture, cellulitis and solid mass.

Management branches

First-line sterileProtect the bursa and preserve movement

Pressure-related posterior swelling is minimally inflamed, skin is intact and infection or fracture is unlikely.

Identify and remove the direct pressure source and provide a properly fitted elbow pad or workplace adjustment.
Use ice, comfortable compression and the safest short analgesic option while continuing gentle elbow movement.
Avoid routine aspiration because fluid often reaccumulates and puncture can introduce infection.
Review if warmth, erythema, fever, drainage, rapid enlargement or impaired joint movement develops.

Key medicines

Topical diclofenac for confirmed sterile painOn intact elbow skin, spread 2–4 g of diclofenac 1.16% gel per dose, using no more than three or four doses daily for a short course and observing the licensed maximum.Do not apply to broken, infected or draining skin, avoid NSAID hypersensitivity and combined excess NSAID exposure, and follow pregnancy restrictions including avoidance in the third trimester.

Oral flucloxacillin for selected stable septic bursitisWhen local antimicrobial guidance supports outpatient treatment, use flucloxacillin 500 mg to 1 g orally four times daily on an empty stomach, commonly for 7 days initially, then review early and extend or change according to culture, depth and response.Immediate hospital care and intravenous therapy are required for systemic illness or deep spread; avoid in severe penicillin allergy, review hepatic and renal history, interactions and pregnancy, and act on culture results.

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