Following minimal trauma or repetitive motion, a
nonarticular synovial sac, or bursa, protecting 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:
Obtain a detailed history of the injury or precipitating
activity document a.thorough physical examination, and rule
out a joint effusion (see below).
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
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.
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.