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Bursitis, Emergency Medicine

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Bursitis, Emergency Medicine

Basics

Description

*NB: The constellation of erythema, warmth, swelling, and exquisite tenderness are common in septic bursitis.

May be difficult to distinguish from fractures; suspicious joints should be immobilized, particularly in the setting of trauma.

Rheumatology or orthopedic referral is recommended for patients who do not respond to intrabursal steroids or recurrent bursitis or need operative management.

  • Bursae are synovial fluid-filled sacs:~150 are located between bones, ligaments, tendons, muscles, and skin.
  • They provide lubrication to reduce friction during movement.
  • Bursitis is inflammation of a bursa caused by trauma and overuse, infection, crystal deposition, or systemic disease.
  • Chronic bursitis can lead to proliferative changes in the bursa.
  • Commonly affected sites:Shoulder (subacromial)Elbow (olecranon): Usually secondary to traumaHip (greater trochanter, ischial, iliopsoas): More common in elderlyKnee (prepatellar and pes anserine): Secondary to trauma or arthritisFoot (calcaneal): Almost always secondary to improperly fitting shoes/heels
  • ~150 are located between bones, ligaments, tendons, muscles, and skin.
  • Shoulder (subacromial)
  • Elbow (olecranon): Usually secondary to trauma
  • Hip (greater trochanter, ischial, iliopsoas): More common in elderly
  • Knee (prepatellar and pes anserine): Secondary to trauma or arthritis
  • Foot (calcaneal): Almost always secondary to improperly fitting shoes/heels

Etiology

  • Trauma (most common cause):Specific traumatic event or repetitive use of associated joints
  • Infection: Secondary to direct penetration; may be obvious or microscopic:Higher risk with diabetes, chronic alcohol abuse, uremia, gout, immunosuppression90% caused by Staphylococcus spp.
  • Crystal deposition: Calcium phosphate, urate
  • Systemic disease: Rheumatoid arthritis, gout, ankylosing spondylitis, psoriatic arthritis, lupus, rheumatic fever
  • Specific traumatic event or repetitive use of associated joints
  • Higher risk with diabetes, chronic alcohol abuse, uremia, gout, immunosuppression
  • 90% caused by Staphylococcus spp.

Diagnosis

Signs and Symptoms

  • Acute or chronic
  • History of trauma, overuse, or prolonged pressure
  • Pain with increased activity at respective joint or with pressure
  • Functional complaints (e.g., limping)
  • History of localized swelling
  • Screen for symptoms of systemic disease
  • History of gout or pseudogout or rheumatologic disease
  • History of recent procedure at bursa (e.g., aspiration, injection, etc.)
  • Tenderness to palpation is minimal to mild in aseptic bursitis.
  • Localized pain with movement
  • Often reduced active range of motion (ROM) with preserved passive ROM
  • Localized swelling, particularly with superficial bursae
  • Skin trauma overlying bursa
  • Warmth and erythema*
  • May be febrile in septic bursitis

Essential Workup

  • Full assessment of adjacent musculoskeletal structures
  • Any suspicion of infection warrants aspiration of bursae (especially olecranon and prepatellar bursae).
  • Lateral approach to prevent a needle tract directly over lines of tension of the joint
  • Aspiration of hip and other deep bursae may be guided in ED by US or deferred to consultants.

Diagnosis Tests & Interpretation

  • Serum labs:Suspected infection: CBC with differentialEvaluation of related systemic disease (e.g., uric acid level for gout); ESR and CRP in rheumatologic diseaseSend serum glucose if bursal fluid aspiration is done
  • Bursal fluid analysis:Send fluid for complete cell count with differential, glucose, total protein, crystal determination, Gram stain, and culture.Cultures must always be sent.Normal fluid: Fluid is clear yellow with 0-200 WBCs, 0 RBCs, low protein, and glucose is same as serum.Traumatic bursitis: Fluid is bloody/xanthochromic with <1,200 WBCs, many RBCs, low protein, and normal glucose.Septic bursitis: Fluid is cloudy yellow with >50,000 WBCs, few RBCs, slightly increased protein, and decreased glucose; bacteria on Gram stain.Rheumatoid and microcrystalline inflammation (aseptic bursitis): Fluid is yellow, sometimes turbid, and has 1,000-40,000 WBCs, few RBCs, slightly increased protein, and variable glucose; microscopic exam for crystals.
  • Suspected infection: CBC with differential
  • Evaluation of related systemic disease (e.g., uric acid level for gout); ESR and CRP in rheumatologic disease
  • Send serum glucose if bursal fluid aspiration is done
  • Send fluid for complete cell count with differential, glucose, total protein, crystal determination, Gram stain, and culture.
  • Cultures must always be sent.
  • Normal fluid: Fluid is clear yellow with 0-200 WBCs, 0 RBCs, low protein, and glucose is same as serum.
  • Traumatic bursitis: Fluid is bloody/xanthochromic with <1,200 WBCs, many RBCs, low protein, and normal glucose.
  • Septic bursitis: Fluid is cloudy yellow with >50,000 WBCs, few RBCs, slightly increased protein, and decreased glucose; bacteria on Gram stain.
  • Rheumatoid and microcrystalline inflammation (aseptic bursitis): Fluid is yellow, sometimes turbid, and has 1,000-40,000 WBCs, few RBCs, slightly increased protein, and variable glucose; microscopic exam for crystals.
  • Radiographs may demonstrate soft tissue swelling or adjacent chronic arthritic changes or calcium deposits:Especially recommended when trauma is involved to rule out fracture or foreign body
  • MRI and US may aid in diagnosis of deep bursitis and in defining the extent of septic bursitis.
  • CT scans can also help differentiate septic from nonseptic bursitis.
  • Especially recommended when trauma is involved to rule out fracture or foreign body

Differential Diagnosis

  • Arthritides: Septic, inflammatory, rheumatoid and degenerative joint (osteoarthritis)
  • Gout and pseudogout
  • Tendonitis, fasciitis, epicondylitis
  • Fracture, tendon/ligament tear, contusion, sprain
  • Osteomyelitis
  • Nerve entrapment
  • Also in hips: Neuritis, lumbar spine disease, sacroiliitis

Treatment

Pre-Hospital

Initial Stabilization/Therapy

  • Immobilize joint if pain is severe.
  • Shoulders should not be immobilized for >2-3 days because of the risk of adhesive capsulitis.

Ed Treatment/Procedures

  • Nonseptic bursitis:Rest and removal of aggravating factors (e.g., avoid direct pressure and repetitive use; protective padding where necessary)Ice affected areas for 10 min, 4 times a day until improved; may alternate with heat.NSAIDs for at least 7 days; best if continued for 5 days after improvement to help prevent recurrenceIf fluctuant, then aspirate and place compression dressingIf no improvement within 5-7 days and infection has been ruled out (by culture), injection of lidocaine and corticosteroids may be considered:Mix 2 mL of 2% lidocaine with appropriate depo-corticosteroid (see below) and inject 1-3 mL of this mixture into the bursa using sterile technique.Steroid injections should not be repeated until 4 wk have passed, and no >2 injections per bursa should be performed without consultation.
  • Septic bursitis:Superficial bursae: Aspiration and antibiotics may be sufficient with close follow-up.Other major bursae: Antibiotics and drainage of bursae (leaving in perforated drainage catheter can reduce period of treatment and avoid eventual bursectomy)Febrile patients may need IV antibiotics.Base antibiotic choice on the Gram stain when available or empiric coverage based on local susceptibilities:Penicillinase-resistant penicillins may be used if Gram stain shows gram-positive cocci in chains but should be broadened for MRSA coverage if cocci in clusters are seenIf gram-negative organisms are found, blood cultures should be done and another primary source for the infection should be sought.
  • Antibiotics should be continued for 5-7 days beyond resolution of signs of infection (thus may require follow-up)
  • Treat associated diseases as needed (e.g., gout).
  • Rest and removal of aggravating factors (e.g., avoid direct pressure and repetitive use; protective padding where necessary)
  • Ice affected areas for 10 min, 4 times a day until improved; may alternate with heat.
  • NSAIDs for at least 7 days; best if continued for 5 days after improvement to help prevent recurrence
  • If fluctuant, then aspirate and place compression dressing
  • If no improvement within 5-7 days and infection has been ruled out (by culture), injection of lidocaine and corticosteroids may be considered:Mix 2 mL of 2% lidocaine with appropriate depo-corticosteroid (see below) and inject 1-3 mL of this mixture into the bursa using sterile technique.Steroid injections should not be repeated until 4 wk have passed, and no >2 injections per bursa should be performed without consultation.
  • Mix 2 mL of 2% lidocaine with appropriate depo-corticosteroid (see below) and inject 1-3 mL of this mixture into the bursa using sterile technique.
  • Steroid injections should not be repeated until 4 wk have passed, and no >2 injections per bursa should be performed without consultation.
  • Superficial bursae: Aspiration and antibiotics may be sufficient with close follow-up.
  • Other major bursae: Antibiotics and drainage of bursae (leaving in perforated drainage catheter can reduce period of treatment and avoid eventual bursectomy)
  • Febrile patients may need IV antibiotics.
  • Base antibiotic choice on the Gram stain when available or empiric coverage based on local susceptibilities:Penicillinase-resistant penicillins may be used if Gram stain shows gram-positive cocci in chains but should be broadened for MRSA coverage if cocci in clusters are seenIf gram-negative organisms are found, blood cultures should be done and another primary source for the infection should be sought.
  • Penicillinase-resistant penicillins may be used if Gram stain shows gram-positive cocci in chains but should be broadened for MRSA coverage if cocci in clusters are seen
  • If gram-negative organisms are found, blood cultures should be done and another primary source for the infection should be sought.

Medication

  • NSAIDs (many choices; a few are listed here):Naprosyn: 500 mg PO q12hIbuprofen: 600 mg PO q6h (peds: 5-10 mg/kg PO q6h)Ketorolac: 30 mg IV/IM q6h or 10 mg PO q4h-q6hMeloxicam: 7.5 mg PO q12h or 15 mg PO daily
  • Corticosteroids for intrabursal injection:Triamcinolone acetonide: 20-40 mg (1st choice)Methylprednisolone acetate: 20-40 mgDexamethasone acetate/sodium: 8 mg
  • Naprosyn: 500 mg PO q12h
  • Ibuprofen: 600 mg PO q6h (peds: 5-10 mg/kg PO q6h)
  • Ketorolac: 30 mg IV/IM q6h or 10 mg PO q4h-q6h
  • Meloxicam: 7.5 mg PO q12h or 15 mg PO daily
  • Triamcinolone acetonide: 20-40 mg (1st choice)
  • Methylprednisolone acetate: 20-40 mg
  • Dexamethasone acetate/sodium: 8 mg

Follow-Up

Disposition

  • Most patients may be treated as outpatients.
  • Most patients respond to therapy in 3-4 days and may follow-up within 1 wk or PRN.
  • Septic bursitis requires repeated bursal aspiration every 3-5 days until sterile.
  • Patients with systemic inflammatory response syndrome (SIRS), large surrounding cellulitis, unable to take PO antibiotics, failed outpatient therapy, or immunosuppressed
  • Unusual organisms, extrabursal primary site, or deep bursal involvement
  • Able to tolerate pain
  • Septic bursitis are safe to discharge if appropriately treated and close follow-up is secure

Follow-Up Recommendations

  • Close follow-up for septic bursitis
  • PRN to the emergency department for worsening symptoms but otherwise follow-up with primary care physician.

Pearls and Pitfalls

  • Exam alone may be unreliable in distinguishing between traumatic and septic bursitis:Aspiration and fluid analysis may be the only method of distinguishing.
  • Beware of risk for GI hemorrhage associated with PO NSAIDs and for nephrotoxicity with ketorolac
  • If presents with the 4 signs of infection-humor, dolor, rubor, and calor-then it is likely septic but still needs an aspiration and culture
  • Beware of the potential of seeding organisms to adjacent joints when aspirating septic bursae.
  • Aspiration and fluid analysis may be the only method of distinguishing.

Additional Reading

  • DeLee JC, Drez D, Miller MD, ed. DeLee & Drezs Orthopaedic Sports Medicine: Principles and Practice. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2010:889-891, 1209-1212, 1246-1249, 1455-1458, 2030-2041.
  • Fayad LM, Carrino JA, Fishman EK. Musculoskeletal infection: Role of CT in the emergency department. Radiographics. 2007;27(6):1723-1736.
  • Larsson L, Baum J. The syndromes of bursitis. Bull Rheum Dis. 1986;36(1):1-8.
  • Stephens MB, Beutler Al, O'Connor FG. Musculoskeletal injections: A review of the evidence. Am Fam Physician. 2008;78(8):971-976.
  • Baumbach SF, Wyen H, Perez C, et al. Evaluation of current treatment regimens for prepatellar and olecranon bursitis in Switzerland. Europ J Trauma Emerg Surg. 2013;39(1):65-72.

Codes

ICD9

  • 726.10 Disorders of bursae and tendons in shoulder region, unspecified
  • 726.33 Olecranon bursitis
  • 727.3 Other bursitis
  • 726.5 Enthesopathy of hip region
  • 726.65 Prepatellar bursitis
  • 726.79 Other enthesopathy of ankle and tarsus

ICD10

  • M70.20 Olecranon bursitis, unspecified elbow
  • M71.9 Bursopathy, unspecified
  • M75.50 Bursitis of unspecified shoulder
  • M70.60 Trochanteric bursitis, unspecified hip
  • M70.21 Olecranon bursitis, right elbow
  • M70.22 Olecranon bursitis, left elbow
  • M70.2 Olecranon bursitis
  • M70.30 Other bursitis of elbow, unspecified elbow
  • M70.31 Other bursitis of elbow, right elbow
  • M70.32 Other bursitis of elbow, left elbow
  • M70.3 Other bursitis of elbow
  • M70.40 Prepatellar bursitis, unspecified knee
  • M70.41 Prepatellar bursitis, right knee
  • M70.42 Prepatellar bursitis, left knee
  • M70.4 Prepatellar bursitis
  • M70.50 Other bursitis of knee, unspecified knee
  • M70.51 Other bursitis of knee, right knee
  • M70.52 Other bursitis of knee, left knee
  • M70.5 Other bursitis of knee
  • M70.61 Trochanteric bursitis, right hip
  • M70.62 Trochanteric bursitis, left hip
  • M70.6 Trochanteric bursitis
  • M70.70 Other bursitis of hip, unspecified hip
  • M70.71 Other bursitis of hip, right hip
  • M70.72 Other bursitis of hip, left hip
  • M70.7 Other bursitis of hip
  • M75.51 Bursitis of right shoulder
  • M75.52 Bursitis of left shoulder
  • M75.5 Bursitis of shoulder
  • M77.50 Other enthesopathy of unspecified foot
  • M77.51 Other enthesopathy of right foot
  • M77.52 Other enthesopathy of left foot
  • M77.5 Other enthesopathy of foot

SNOMED

  • 84017003 Bursitis (disorder)
  • 239961006 Bursitis of shoulder (disorder)
  • 425940002 inflammation of bursa of olecranon (disorder)
  • 81498004 bursitis of hip (disorder)
  • 111243002 bursitis of knee (disorder)
  • 287025008 Bursitis - ankle/foot (disorder)