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/

Dislocation of the Hip

Dislocation of the Hip

Hip dislocation can be either a simple dislocation or it can be a fracture dislocation which involves the posterior wall of the acetabulum or the femoral head. Dislocation of the hip can be two types: posterior dislocation (most common type) or anterior dislocation (rare). hipPosition of the hip during the impact decides the injury. In posterior dislocation of the hip, which is the commonest type, the lower limb will be flexed, adducted, and internally rotated. Anterior hip dislocation is rare. It could be a superior anterior hip dislocation. The limb will be extended, abducted, and externally rotated. With an anterior inferior dislocation (obturator type), the extremity will be flexed, abducted, and externally rotated. Hip fractures are different than hip dislocations. Notice that the affected extremity is shortened and externally rotated with a hip fracture. Hip dislocation of any type is an emergency. It must be reduced in less than 6 hours of injury. After reduction of the hip, get a CT scan. Although x-ray is helpful, a CT scan clearly outlines the bony injury. Check the CT scan for congruous reduction, for absence of fracture, and absence of marginal impaction in the acetabulum (with posterior wall fracture, check for marginal impaction). Marginal impaction is more common in posterior acetabular wall fractures and could lead to instability. hip diDisplaced or comminuted posterior wall fracture could lead to arthritis. Make sure that you have good congruous reduction with no loose bodies or important fractures present. Check for fractures of the acetabulum and the size of the fragment. The size of the posterior wall fracture has an effect on the stability of the hip joint. If congruous reduction of the hip is not obtained, perform open reduction urgently. Open reduction can be done through an anterior approach or a posterior approach. Hip dislocation with or without associated fracture can cause complications. The risk of avascular necrosis depends on the interval between the injury and reduction of the dislocation. Urgent reduction of hip dislocation is mandatory to avoid AVN and interruption of the blood supply which leads to collapse of the femoral head. Reduce the hip and recheck the sciatic nerve function. Always reduce the hip early. Closed reduction should be done in less than 6 hours. hip disWhen injury occurs to the sciatic nerve due to posterior hip dislocation, the common peroneal nerve is usually affected, causing weakness in dorsiflexion of the ankle and loss of toe extension. Injury can occur in varying degrees of severity and it can be missed. Check for foot drop. Movement of the toes may be misleading. Movement of the toes may appear as dorsiflexion, however this really is the result of plantar flexion. Documenting the injury is important to avoid medical legal problems. Injury to the sciatic nerve usually occurs from the dislocation and not from the reduction of the hip. The longer the wait for the reduction of the dislocation, the more the patient is predisposed to sciatic nerve injury. The length of time a hip remains dislocated influences the incidence and the severity of a major sciatic nerve injury. Patient recovery of the sciatic nerve occurs in 60-70% of patients. The patient usually requires an anti-foot drop splint to prevent equinus of the ankle. hip dThere is approximately 10% incidence of sciatic nerve palsy from posterior hip dislocation. Neurologic examination at the time of injury is usually difficult, however, it is extremely necessary. Check for sensation on the top of the foot. In posterior dislocation of the hip, always look for injuries in the knee such as with a dashboard injury. The force of the injury is usually transmitted from the knee to the hip. There may be an associated posterior cruciate ligament (PCL) injury or a meniscal tear. Examine the knee for injuries and an MRI of the knee may be needed. In cases of high energy trauma, always look at the chest. There might be a tear of the aorta. Check for widening of the mediastinum on chest x-rays. There is concern of deceleration injury involving the aorta. You may apply advanced trauma life support (ATLS) protocol. More flexion, internal rotation, and adduction favors pure dislocation of the hip. Less flexion, internal rotation, and adduction favors fracture dislocation of the hip. Hip dislocation may be associated with acetabular fracture or fracture of the femoral head (Pipkin fracture). hip dislWith Pipkin fracture, as the femoral head dislocates, it hits the posterior wall of the acetabulum and the femoral head fractures. This may be different from an anterior hip dislocation. Anterior hip dislocation will cause impaction of the femoral head or indentation fractures. Classically, Pipkin fracture is a posterior dislocation of the hip and fracture of the femoral head. To treat this, do emergency closed reduction of the hip within 6 hours. Closed reduction is done to avoid avascular necrosis (AVN) of the hip. Reduction of the hip joint and mobilization of the patient with protected weight-bearing crutches for 4-6 weeks. After closed reduction, when the patient has an associated fracture, assess the hip stability, especially if the fragment is not too large. The hip is usually stable if the fragment size of the acetabulum is less than 20%. More than 40%, the hip is unstable. Between 20%-40% fragment size, the hip stability is undetermined. When there is an associated acetabular fracture, the best method to assess the stability of the hip is by examination of the patient under general anesthesia utilizing fluoroscopy. Asses the posterior wall stability with the obturator oblique view. Hip will be in flexion, adduction, and add axial load. hip disloCheck the medial clear space for opening (opening of the medial clear space suggests instability of the posterior wall fracture. Irreducible isolated posterior dislocation; do emergency surgical treatment to reduce the hip. If there is an associated acetabular fracture or femoral head fracture, do urgent closed reduction of the hip dislocation followed by stabilization of either of the fractures if needed according to the protocol. For a posterior hip dislocation with posterior acetabular wall fracture, you must assess the stability of the hip joint by examination under anesthesia after closed reduction. After closed reduction, if the dislocation is not congruent, do open reduction and fixation urgently. For a Pipkin femoral head fracture, do headless screw fixation.

Girdlestone Procedure for Femoral Neck Fractures in the Elderly

Girdlestone Procedure for Femoral Neck Fractures in the Elderly

Girdlestone procedure is a salvage procedure. It means removal or resection of the neck of the femur. The diseased femoral head is cut off with a bone saw. It means removal or resection of the head and neck of the femur. The affected femoral head is removed as you can see in this picture. Girdlestone is usually done in the following situations: patient has a severely painful hip and a total hip replacement cannot be done such as in cases of severe infection of the hip or in a nonabulatory cerebropalsy patient with a painful hip dislocation. It can also be done in selective tumors of this area. girdThe procedure is referred to as a “salvage” procedure. It is the lesser of two evils or it is the final alternative procedure. This procedure may have a role in cases of displaced femoral neck fractures or in cases of failed internal fixation of femoral neck fractures in debilitated elderly patients. Let’s agree that in the elderly patient, hip prosthesis either unipolar or bipolar and usually cemented, is the ideal surgical procedure for displaced femoral neck fractures, especially if the patient is debilitated and old. In an active elderly patient, total hip replacement should be considered. Sometimes the medical condition and the age of the patient does not support or allow the use of a prosthesis in the elderly. I use the girdlestone procedure in some cases of displaced femoral neck fractures in the elderly, especially if the patient is debilitated and nonambulatory, and when the medical comorbidities are almost prohibitive for surgery. Comorbidities include chronic renal failure, COPD, and congestive heart failure. Even if the prosthesis could be done, the pre-injury cognitive and physical function is predictive of post-operative functional outcome after hip fracture surgery and this select group of patients will not be functional with the prosthesis. The purpose of the Girdlestone procedure is to decrease the pain and to preserve the life of the patient despite the considerable shortening of the extremity. It is an alternative to hospice or alternative care. grdIt is the simplest and the least complex procedure for the patient. Counseling to the patient and the patient’s family should be done. The Girdlestone procedure can be done anteriorly or posteriorly. You do not need traction post-operatively. You should get the patient out of bed immediately, and you should do physical therapy early. You will keep the patient in a step down or ICU for a few days after surgery. The patient should be admitted by the geriatric services in cooperation with the trauma services. Surgery should be done within 48 hours or as soon as the patient is optimized medically because that could decrease the mortality rate. Sometimes optimization of the patient is not that easy. The mortality rate is 25% at one year and 6% during hospitalization. The pre-injury mobility is the most significant determining factor for post-operative survival. In patients with femoral neck fractures, surgery done on weekends was associated with an increase in hospital mortality rate, so it is better to do this surgery on week days. If you try to do a simple procedure such as fixation of the displaced femoral neck fracture, the failure rate is about 46% with fixation techniques in the elderly. There is a growing number of people over 90 years of age who will suffer from femoral neck fractures and these patients will need decisions and appropriate care for their situation. Advanced age is associated with increased mortality and poor functional recovery, so we need to think of new ways to approach the increased number of femoral neck fractures in the elderly, and I think that Girdlestone procuedre should be utilized in some select indications.

Acetabular Fracture- Associated Both Columns

Acetabular Fracture- Associated Both Columns

Associated both column fracture is fracture of both columns of the acetabulum. Both columns are separated from each other and from the axial skeleton, resulting in a floating acetabulum. This is the most complex type of acetabular fracture. The fracture type used to be called “central acetabular fracture”. This fracture pattern may be associated with central dislocation and no part of the articular surface remains attached to the axial skeleton. The acetabular fragments become free and rotate around each other. They may appear to maintain congruity to the femoral head. There is dissociation of the articular surface from the axial skeleton. Because of this secondary congruity, traction may be used in the treatment of associated both column fracture in the elderly. You will see the “spur sign” above the acetabulum on the obturator oblique view and this is diagnostic for associated both column fracture. In the obturator view, you will find the anterior column (iliopectineal line) is disrupted and you will find the “spur sign”. The “spur sign” is the posterior inferior aspect of the intact posterior ilium. Another feature of the associated both column acetabular fracture is the Judet sign of the curved line. The Judet sign of the curved line occurs due to interruption by the fracture of the iliopectineal line. acxThe curved line belongs to the greater sciatic notch and if after fixation anteriorly, the patient has a positive curved line sign, then the posterior column is probably not reduced. The roof of the acetabulum is involved either totally or partially. When you see an x-ray and the roof of the acetabulum is in pieces, then this injury is probably an associated both column fracture. You will see a coronal plane fracture through the iliac wing. In general, see Coronal for Column fracture. If you have both column fracture and there is an additional fracture going to the ilium, then this is an associated both column fracture. In CT scan, the fracture will be coronal. T-shaped fracture of the acetabulum is different from an associated both column fracture of the acetabulum. In associated both column fracture of the acetabulum, the fracture goes through the ilium. The acetabulum is floating and is disconnected from the axial skeleton. If you see extension of a transverse fracture of the acetabulum through the medial wall of the acetabulum and the fracture is going through the obturator ring, then this is a T-shaped fracture. The ilioinguinal approach is the main approach used to treat associated both column fractures.