9.11 Bursitis
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agk's Library of Common Simple Emergencies

Presentation
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Following minimal trauma or repetitive motion, 
a nonarticular synovial sac, or bursa, protect- 
ing 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:
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- Obtain a detailed history of the injury or 
    precipitating activity thorough physical 
    examination, and rule out a joint effusion 
    ([Traumatic effusion]).
- 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
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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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img/cse0911.gif

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