Background/Purpose . Olecranon bursitis is a common presentation to an outpatient rheumatology practice. The differential diagnosis includes crystalline bursitis (gout and pseudogout), inflammatory bursitis due to systemic arthritis such as rheumatoid arthritis, infectious, and hemorrhagic. We have observed a larger than expected percentage of hemorrhagic olecranon bursitis in our practice and wanted to report our experience with this entity and its management.

Methods . We systematically looked for the ICD9 diagnosis code 726.33 in our academic rheumatology outpatient practice from 2011-2014. We recorded the patents demographic information, as well as clinical examination findings, bursa fluid analysis, and response to glucocorticoid injections. We defined inflammatory cases when the tissues around the swelling were erythematous and hot and the synovial fluid was inflammatory (>2,000 WBC with predominance of PMN). Non-inflammatory cases were defined when none of the above were present. A bursitis was defined as infectious when a culture was positive and possibly infectious when culture was negative but there were no crystals in the fluid. Hemorrhagic bursitis was identified when the bursa fluid had the appearance of pure blood. A bursa was defined as large when its diameter was >5 cm (larger than golf ball), intermediate when its diameter was 2.5-5 cm and small when its diameter was <2.5 cm

Results . We identified 9 patients. Of those, 6 were non inflammatory in appearance. All of them proved to be hemorrhagic and negative for infection on culture. The remaining 3 were inflammatory, but no crystals were identified in the fluid under polarizing microscopy. The fluid was yellow opaque in 2 of those cases and in one case there was only 1 drop of blood which was hemorrhagic in appearance. The 6 hemorrhagic cases were injected with depomedrol 40 mg and five had a dramatic response within few days-few weeks. We had no follow up in 1 patient. Of 3 inflammatory cases, one had a documented infection with MSSA, another one responded well to antibiotics, and another was lost to follow up. Of note, all of our patients were males with an average age of 54 (range: 32-72), relatively high BMI (average 30.5 with range: 21-45). Of the 6 hemorrhagic cases, 4 were large and 2 intermediate in size. Two of the inflammatory cases were small and one large. One out of 6 hemorrhagic bursa patients was on warfarin and another on dabigatran.

Conclusion . Hemorrhagic bursitis is not uncommon and should be suspected when there is no inflammation on examination. Middle age men, especially those with higher BMIs, and perhaps those on anticoagulation appeared to be at higher risk for this entity. Our experience suggests that an injection with glucocorticoids is an effective treatment strategy and leads to resolution or marked improvement within few days-few weeks.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/olecranon-bursitis-is-often-hemorrhagic-and-responds-to-steroid-injections/