Bursitis of the Knee, Hip, Elbow and Shoulder — Everything You Need to Know

Written by Andrew Kelley with Dr. Nabil Ebraheim

Prepatellar Bursitis of the Knee

Prepatellar bursitis, also known as housemaid’s, carpet layer’s, and carpenter’s knee, is a superficial bursitis caused by inflammation of the bursa separating the patellar bone and the skin (1). Patients with prepatellar bursitis will normally present with knee pain and swelling (2). Prepatellar bursitis is mostly caused by long-term repetitive mini trauma from kneeling and crawling on hard surfaces. Other causes include acute injury, infection, gout, and rheumatoid arthritis (2). Its annual incidence is 10/100,000 per year with 80% of those affected being males age 40-60 (1). In cases of non-traumatic prepatellar bursitis, treatment is dependent on resolution of the underlying condition. Early differentiation between septic and non-septic bursitis is important in the early presentation in order to improve patient outcomes. Acute bursitis normally responds well to conservative treatment such as rest, ice, activity modification, NSAIDs, and fluid aspiration. Chronic bursitis due to mini traumas is treated similarly but may require additional corticosteroid therapy (1).

Olecranon Bursitis of the Elbow

Olecranon Bursitis, also known as student’s elbow and plumber’s elbow, is caused by inflammation of the bursa overlaying the olecranon process of the ulnar bone at the tip of the elbow. This bursa allows for smooth motion of the olecranon process against the superficial tissue at the tip of the elbow. Affected patients normally present with swelling at the bend of the elbow. A characteristic “golf ball” shape of swelling can be seen, and a fully intact range of motion of the elbow can differentiate it from elbow joint injuries (3). Olecranon Bursitis most commonly affects men age 30-60. Most cases are due to repeated minor trauma and sports (4). Treatment is focused on resolving the underlying cause of inflammation. Conservative treatment includes ice and rest along with NSAIDs for symptomatic relief are indicated. While aspiration and corticosteroid injection are proven relief interventions, they carry an increased risk for infection (4).

Greater Trochanteric Bursitis of the Hip

Greater trochanteric bursitis, or greater trochanteric pain syndrome (GTPS), is caused by inflammation of the bursa laying deep to the iliotibial band and superficial to the greater trochanter of the femur. It acts as a lubricant for the gluteal tendons. Patients with hip bursitis normally present with chronic intermittent pain of the lateral hip, thigh, and buttock (6). This bursitis normally affects women age 40-60. The increased pelvic width of women relative to their body may predispose them to increased iliotibial band tension on the bursa (6). The cause of hip bursitis can be repetitive microtrauma, blunt trauma, or idiopathic. Movements requiring repetitive hip abduction like stair climbing and bicycling, direct traumatic falls, and sedentary lifestyles are common causes of this condition (5).  Common treatments for this bursitis include NSAIDs, physical therapy, and corticosteroid injection. Surgery is a rare treatment option for bursitis resistant to conservative treatment options (5).

Subacromial Bursitis of the Shoulder

Subacromial bursitis is caused by inflammation to the bursa just below the acromion process. The subacromial bursa acts as a lubricating medium between the acromion process superiorly and the muscles of the rotator cup inferiorly.  Subacromial bursitis normally presents as anterolateral shoulder pain, especially during overhead activities. This chronic inflammation of the shoulder bursa can eventually lead to weakness and rupture of the surrounding ligaments and tendons (7). Older individuals are more likely to experience shoulder bursitis due to years of overuse. Most patients present due to direct trauma to the shoulder or repetitive overhead activities (7). Treatment includes rest, NSAIDs, physical therapy, and corticosteroid injections. Surgical therapy is reserved for cases unresponsive to conservative therapy (7).

References:

  1. Rishor-Olney CR, Pozun A. Prepatellar Bursitis. [Updated 2021 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
  2. J. Dean Cole MD. Causes of knee bursitis (prepatellar bursitis) [Internet]. Arthritis. Arthritis-health; [cited 2021Oct28]. Available from: https://www.arthritis-health.com/types/bursitis/causes-knee-bursitis-prepatellar-bursitis
  3. Pangia J. Olecranon bursitis [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct28]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470291/
  4. Blackwell JR, Hay BA, Bolt AM, Hay SM. Olecranon bursitis: a systematic overview. Shoulder Elbow. 2014 Jul;6(3):182-90. doi: 10.1177/1758573214532787. Epub 2014 May 6. PMID: 27582935; PMCID: PMC4935058.
  5. Seidman AJ. Trochanteric bursitis [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct28]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538503/
  6. Reid D. The management of Greater Trochanteric pain syndrome: A systematic literature review [Internet]. Journal of orthopaedics. Elsevier; 2016 [cited 2021Oct28]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4761624/
  7. Faruqi T. Subacromial bursitis [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct29]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541096/

Fracture of the Radial Head Essex Lopresti

Fracture of the Radial Head Essex Lopresti

Essex Lopresti fracture is a radial head fracture with disruption of the interosseous membrane and an injury to the distal radioulnar joint (DRUJ). Injury of the DRUJ can be subluxation or dislocation of that joint. The Essex Lopresti injury affects the axial stability of the forearm. It is an injury to the interosseous membrane and the triangular fibrocartilage complex which could result in proximal migration of the radius. radThe Essex Lopresti fractures is difficult to diagnose, and the physician must restore the stability of the elbow and the DRUJ. Radial head fractures are a common elbow fracture and constitutes about 1/3 of elbow fractures. The mechanism of injury is usually a fall onto an outstretched hand. The elbow will be in extension and pronation. There will be axial loading transmitted from the wrist to the radial head, which is combined with a valgus force, and this will create a fracture of the radial head. The radial head provides two types of stability: valgus stability and longitudinal stability. The radial head is secondary restraint to valgus load at the elbow, and it prevents proximal migration of the radius with some contribution from the interosseous membrane. Loss of this longitudinal stability occurs when the radial head fractures, plus injury to the DRUJ, and the interosseous membrane will become ruptured in this situation. frIn this situation, the radial head should be fixed or if the radial head is unreconstructable, replace the radial had by a radial head prosthesis, but never resect the radial head alone in this situation without replacing it. If fixation cannot be achieved, the prosthetic replacement must be done. Radial head excision will result in proximal migration of the radius and ulnocarpal impingement with distal radioulnar joint instability. In reality, when you go to surgery with these cases, the fractures look more comminuted than expected. The problem is that not all hospitals are equipped with radial head prosthesis. If you take the patient for radial head work, make sure that you have the implant in house just in case the fracture is unreconstructable. You can excise the radial head if all ligaments are intact, but the problem is that you may not know that the DRUJ is involved. There are four types of radial head fractures. Type I is a nondisplaced fracture which has no block to forearm rotation. It has an early range of motion and does not require surgical treatment. Type II is a displaced fracture more than 2 mm. it requires fixation by screws or a plate. Type III is a comminuted fracture that is displaced or irreparable. It requires excision and prosthesis typically a metallic modular prosthesis. Excision alone can be done in some situations. Before you excise the radial head fracture, you must make sure all ligaments are intact, that you examined the patient and that there is no distal radioulnar joint (DRUJ) injury or elbow injury. If you have a patient with a comminuted radial head fracture, it is probably safer to replace it. Type IV fractures are associated with dislocation of the elbow joint. You should attempt to reduce the elbow joint with fixation of the fracture. This can be done with a plate or screws. Excision of the radial head and prosthetic replacement if the fracture is unreconstructable (cannot be repaired). Excision of the radial head alone is contraindicated in elbow dislocation or in Essex Lopresti fracture. To examine Essex Lopresti Fractures, you must first examine the DRUJ. Palpate the wrist for tenderness and excessive translation of the DRUJ. Examination of the DRUJ is very difficult; be sure to check the x-rays carefully. sqYou will examine and palpate the interosseous membrane for tenderness. You may want to do the squeeze test, similar to what you do to check for high syndesmotic injury of the ankle and check if there is any tenderness there. You may want to get dynamic CT scans before surgery (it may show you some instability at the DRUJ. In surgery, you will do the radius pull test. More than 3mm of translation is concerning for longitudinal forearm instability (Lum & Trzeciak, 2018). Surgery for radial head fractures is done through posterolateral (Kocher) approach between the ECU and Anconeus muscles or through the lateral approach. Watch the safe zone for implant insertion to avoid impingement and loss of rotation. The radial head prosthesis usually I s cementless and acts as a stiff spacer until the ligaments heal, so it doesn’t have to be very snug into the canal (may fracture the proximal radius). You can use the modular system to check for the appropriate height. Make sure that you do not over stuff it. Visually assess widening of the lateral ulnohumeral joint, and also make sure that you are not blocking extension. In general, if the radial head fracture is less than three fragments, then ORIF is good. If there are more than three fragments, using a prosthesis is better. You want to keep the lateral ulnar collateral ligament (ulnar humeral ligament) intact and stay above the equator of the radial head. When you stay above the equator in the radial head, it is less likely that you will injure the lateral ulnar collateral ligament (LUCL). Make sure that you understand the position of the posterior interosseous nerve which is about 4 cm. the posterior interosseous nerve crosses the proximal radius from anteriorly to posteriorly within the supinator muscle, 4 cm distal to the radial head. When you do the surgery, you want to pronate the forearm to protect the posterior interosseous nerve. Pronation pulls the nerve anteriorly away from the surgical field.

Pediatric Elbow Dislocation in Children

 

Pehttps://www.youtube.com/watch?v=IfcCTQtQFLkdiatric Elbow Dislocation in Children

There are five conditions connected to elbow dislocations in children: pediatric elbow dislocation, pulled elbow (nursemaid’s elbow), congenital dislocation of the radial head, monteggia fracture, and transepiphyseal separation of the distal humerus. dislA pediatric elbow dislocation by itself occurs in older children between 10-15 years old. It is rare before the age of 3, and it is not a very common injury. The elbow dislocation is usually posterolateral.There is no relationship between the radial head and the capitellum, but you maintain the relationship between the radius and the ulna, so it is an elbow dislocation and not a Monteggia. The treatment of the pediatric elbow dislocation is closed reduction and early range of motion. This condition may have an associated medial epicondyle fracture.  Check if the medial epicondyle fracture is entrapped in the joint or not. The joint will appear incongruous. This fragment may be hard to detect especially if there is a spontaneous reduction of the elbow by itself. After reduction, if the fragment is still in the joint or if there is substantial fragment displacement, this is an indication for surgery (ORIF). Pulled elbow, or nursemaid’s elbow, is a common injury in young children between the ages of 2-3 years old. When pulling the child’s arm, the child goes in one direction and the parent goes in another direction, causing the annular ligament to become torn and trapped inside the joint and the radial head may be sublexed. This is not an elbow dislocation. It is a pulled elbow where the child refuses to move the elbow and the position of the arm of the child will be slightly flexed but pronated. When you get the x-rays, the x-rays are negative. It can be treated by reduction. elbowIt should be reduced by full supination of the arm followed by flexion and there will be no need for immobilization of the arm, let the child use the arm. In order to test if the elbow is reduced, you should give the child a piece of chocolate or candy. If the child can bend the elbow (flex the elbow) so he can have the piece of chocolate in his mouth, then that elbow is reduced. Congenital dislocation of the radial head is usually bilateral, and you can’t reduce it. There will be no significant history of trauma and the capitellum looks hypoplastic. You will find that there is posterior dislocation of the radial head, and the radius is bowed and shortened. You should check for other anomalies and if the condition is symptomatic, you will do radial head resection in adulthood. Monteggia fracture is a proximal 1/3 ulnar fracture and radial head dislocation or subluxation. The condition may be difficult to diagnose, and if the diagnosis is delayed, then the treatment will be complicated, and there will be more complications. Make sure that there is not a posterior interosseous nerve injury. The diagnosis is difficult because the fracture of the ulna may not be very apparent, but you have to look at the radial head position in relationship to the capitellum. The most common type of Monteggia dislocation is anterior dislocation of the radial head (check the relationship of the radial head and the capitellum. In Monteggia fracture, the radial head is the one that is dislocated and not the elbow. The relationship between the radial head and the ulna is also interrupted. If you do not get anatomic alignment of the ulna, the radial head may continue to sublex, and the ulna will heal in a bad position with the radial head dislocated. This condition will need osteotomy of the ulna and open reduction of the radial head. Differentiating pediatric elbow dislocation from transepipyseal separation of the distal humerus can be difficult. Because there is no clearly visible ossific centers at the distal humerus at the younger age, this condition can be misdiagnosed as an elbow dislocation. In pediatric elbow dislocation, the olecranon moves posteriorly and laterally. Pediatric elbow dislocation does not occur in children at 1 or 2 years old. Transepiphyseal separation of the distal humerus usually occurs in a younger age group than an elbow dislocation. The distal fragment goes medially. In transepiphyseal separation, you will find that the radiocapitellar line remains the same. When you have this condition of transepiphyseal separation of the distal humerus, consider child abuse, look for other signs of abuse.

Cubital Fossa

Cubital Fossa

Cubital FossaThis is about understanding the arrangement of the structures in the anterior elbow. This is an anatomy video, but this can also help surgeons in knowing how to approach the insertion of the distal biceps for repair or how to approach the proximal radius fracture anteriorly. If you look at the bony structures of the anterior elbow, you need to find out where the common flexor tendon origin is, where the brachialis muscle is inserted, and where the biceps is, supinator and the pronator teres located. These structures are definitely part of the anterior elbow. The cubital fossa is a triangular depression located in front of the anterior elbow. The medial border is formed by the pronator teres, which arises from the medial epicondyle of the humerus. The lateral border of the cubital fossa is formed by the brachioradialis muscle which arises from the lateral supracondylar ridge of the humerus. The meeting of these two muscles forms the apex of the cubital fossa. The brachioradialis muscle overlaps the pronator teres, so the lateral border overlaps the medial border. The base of the cubital fossa is superior and is represented by a horizontal line connecting the two epicondyles of the humerus, the lateral and medial epicondyles.

Structures Located In and Around The Cubital Fossa

The base of the cubital fossa is seen as an imaginary line drawn between the medial epicondyle and the lateral epicondyle of the distal humerus. The pronator teres is the medial border, and the brachioradialis muscle forms the lateral border. The contents of the cubital fossa from medial to lateral are median nerve, brachial artery, biceps tendon, and radial nerve. The floor of the cubital fossa is made up of the lower part of the brachialis muscle medially and the supinator muscle laterally. The roof of the cubital fossa is made up of skin, fascia, and the bicipital aponeurosis. CFS

The median nerve disappears by entering the forearm between the two heads of the pronator teres muscle. The brachial artery bifurcates into the ulnar artery and the radial artery. The brachial artery is over the brachialis muscle. The ulnar artery leaves the fossa by going under the deep head of the pronator teres muscle. The deep head of the pronator teres muscle separates the median nerve, which goes between two heads of the pronator teres muscle from the ulnar artery, which goes deep to the deep head of the pronator teres muscle. Another branch that is in the cubital fossa is the radial artery. The radial artery descends laterally and is overlapped by the brachioradialis muscle. The biceps tendon is lateral to the brachial artery within the cubital fossa. The biceps tendon has one main insertion laterally to the radial tuberosity and another insertion going medially to the bicipital aponeurosis. The bicipital aponeurosis covers and protects the vital structures medially to the biceps tendon (brachial artery and median nerve). The biceps tendon passes backwards (twisted) towards its insertion into the radial tuberosity. Lateral to the biceps tendon is the radial nerve and its major branch, the posterior interosseous nerve. Other important nerves in the vicinity of the cubital fossa include the superficial radial nerve which is below the brachioradialis and the lateral cutaneous nerve of the forearm which is a branch of the musculocutaneous nerve and lies below the biceps proximally and then finally lies laterally.