1

What is olecranon bursitis and what are the most common causes?

Inflammation of the bursa overlying the olecranon process of the ulna. Common causes include isolated trauma, repetitive microtrauma, gout, pseudogout, and autoimmune diseases such as rheumatoid arthritis and infection.

2

Can trauma lead to septic olecranon bursitis? What are the most common bacteria found in septic olecranon bursitis?

Yes, trauma can lead to both septic and nonseptic olecranon bursitis with Staphylococcus aureus being the causative factor in 80% of cases. Patients exposed to repetitive pressure leading to microtrauma to the elbow region are at increased risk for developing bursitis.

3

What signs and symptoms are suggestive of septic bursitis?

Fever, warmth when compared to the unaffected side, erythema, and pain with passive range of motion (ROM) may all be found in all forms of bursitis; they are suggestive but not fully reliable for the diagnosis of septic bursitis. In addition, the absence of any of these signs and symptoms cannot reliably be used to rule out septic bursitis.

4

What is the recommended treatment?

In the absence of infection, most patients respond to a series of joint aspirations, sometimes with corticosteroid injections. Septic bursitis requires antibiotics, typically Bactrim DS (5 mg trimethoprim [TMP]/kg) 1 tabs oral twice daily (PO BID) or clindamycin 600 mg (10 mg/kg) three times daily (TID) for 14 days for mild to moderate cases. More significant cases require inpatient management.

5

What is the technique for aspiration?

After skin is sterilized and the area is anesthetized, using an 18-gauge needle attached to a syringe, insert the needle into posterior/lateral aspect of the bursa, taking a parallel approach to the joint ( Fig. 10.1 ). Avoid medial approach as this could damage the ulnar nerve. Aspirate fluid from bursa until it is flat. Then withdraw the needle and wrap the elbow with compression dressing.

Injection technique for olecranon bursitis pain.

From Waldman SD: Atlas of Pain Management Injection Techniques . Philadelphia, Saunders, 2007, p 181.

6

What should be ordered for aspiration fluid analysis?

Crystals, cell count, gram stain, and culture.

7

What is the most reliable way to rule out septic bursitis?

While aspiration with a cell count >30,000 is thought to be suggestive of infection, a count less than this does not reliably rule out septic bursitis; Gram stains will be positive in only 50% of the cases of infection. The only definitive test to rule out septic bursitis is a negative culture result. Considering the difficulty in ruling out an infectious cause, empiric antibiotic coverage until cultures of the fluid have returned with no bacterial growth have resulted is a reasonable approach.

8

What is carpal tunnel syndrome and what about its anatomic location makes it such a common condition?

Carpal tunnel syndrome is a peripheral neuropathy caused by compression of the median nerve. The median nerve is found within the carpal tunnel, which is a restricted space between the carpal bones and the flexor retinaculum. Any type of inflammation, edema, or swelling in this very confined space can lead to nerve compression, resulting in the symptoms of median nerve neuropathy.

9

What are the classic clinical tests for carpal tunnel syndrome?

The classic maneuver that causes the carpal tunnel narrowing leading to ulnar nerve compression is known as Phalen’s sign. This is achieved by pressing the dorsum of the hands together, resulting in flexion of the wrists for approximately one minute. A positive sign is one that elicits paresthesias in the median nerve distribution: the thumb, index, long finger, and half the ring finger.

The alternative maneuver is Tinel’s sign. This is achieved by direct nerve stimulation by tapping the volar aspect of the wrist and causing paresthesias along the median nerve distribution.

10

What is the initial treatment of carpal tunnel syndrome?

Avoidance of repetitive wrist motions that may have led to the initial inflammation. Ergonomic devices to help eliminate poor wrist position, wrist splinting, and nonsteroidal antiinflammatory drugs (NSAIDs). If symptoms are severe or initial NSAID treatment has failed, steroid injections can be considered.

11

What surgical options are there and what at the indications for surgery?

Although most patients initially respond to conservative treatment, 80% will have a recurrence of symptoms at one year. If a patient fails conservative treatment or continues to have recurrence of symptoms, consider surgical release of the retinaculum.