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Three Part Question

In [adults with a clinical diagnosis of olecranon bursitis] does [diagnostic aspiration of the bursa] lead to [better diagnosis and outcome]?

Clinical Scenario

A 45 year old labourer presents to the Emergency Department with a one day history of pain and swelling over his right elbow. Examination reveals a generally well, apyrexial man with a swollen, warm right olecranon bursa with overlying redness. You wonder whether it is necessary to aspirate and analyse bursal fluid to diagnose an treat this patient.

Search Strategy

Medline 1966-11/03 using the OVID interface.
[exp elbow OR exp elbow joint OR olecranon$.mp] AND [bursa$.mp OR exp bursa,synovial OR exp bursitis OR bursitis.mp] LIMIT to human AND English language AND abstracts.

Search Outcome

136 papers found of which 3 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ho G Jr & Tice AD, 1979, USA	30 consecutive patients with olecranon (25) or pre patellar (5) bursitis 20 non-septic and 10 septic	Survey	Predominant white cell type	mononuclear vs polymorphonuclear	Small numbers No statistical analysis
			White cell count	1,523 vs 108,630 per mm³
Stell IM & Gransden WR 1998 UK	36 patients with olecranon (28) or pre patellar (8) bursitis 19 non-septic and 17 septic	Diagnostic	Median white cell counts	Sensitivity 94%, specificity 79% at > 2 x 109 / l	Small numbers Gold standard was expert opinion
			Culture in liquid medium	Sensitivity 100%, specificity 89%
Stell IM 1999 UK	47 patients with bursitis. 32 had olecranon bursitis	Observational Cohort	Number of olecranon patients with sepsis on culture	15/32 (47%)	Small study with fairly wide confidence intervals. All patients were aspirated - not know if it was possible to correlate microbiological findings with presenting features.

Comment(s)

While two studies addressed the diagnostic question alone, no comparitive studies could be found regarding the usefulness of diagnostic aspiration in improving outcome. The papers do suggest that a large number of bursitis patient have definable infection; though the sensitivity of white cell analysis is just too low for use as a SnOut. Liquid culture, while absolutely sensitive, takes so long that blind treatment will usually be necessary until the result is available. Our clinical practice does suggest that some patients have very few signs of infection though there are no papers that correlate clinical findings with microbiological diagnosis - which would be useful.

Editor Comment

Search repeated in Nov 2003.

Clinical Bottom Line

If septic bursitis is suspected then antibiotics (anti-staphylococcal) should be started. Initial aspiration may be useful in determining whether sepsis is the underlying cause and in defining when to stop treatment.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Ho G Jr, Tice AD. Comparison of Nonseptic and Septic Bursitis. Further Observations on the Treatment of Septic Bursitis. Arch Int Med 1979;139:1269-1273.
2. Stell IM, Gransden WR. Simple tests for septic bursitis: comparative study. BMJ 1998;316:1877.
3. Stell IM Management of acute bursitis: outcome study of a structured approach Journal of the royal society of medicine 516-518