Case Report Bursitis

8/10/2019 Case Report Bursitis

1/19

CASE REPORT

I.I Patient Personal Data

Name : Mr3. . FA

Age : 42 years

Gender : Female

Address : Tegal Gubug

Occupation : House i!e

"eligion : #slam

I.2 Anamnesis

The main complaint :$e!t elbo% lump

History Disease Now :

T&e patient came to t&e emergency room Ar'a%inangun &ospital complaining %it& $e!t elbo%

lump since 2 mont& ago. (&e told t&at lump at begingging %as small and by t&e time goes !ly t&e

lump become bigger. (&e !elt pain on t&at lump. (&e told t&at lump distract daily accti)ities.

T&e lump !ell li*e so!t and slipery. And t&e lump easy to mo)e.

Past history o !isease :

History o! Heart +isease , -

History o! "enal +isease , -

"amily history o !isease :

History o! &eart disease , -

+isease &istory +M , -

History o! allergy medicines , -

I.# Physical E$amination

General state : /M

0ital (ign :

T+ : 13 5 lying 5 rig&t arm 5 t&e cu!! adult

Nadi : 6menit 5 regular 5 pulse enoug& content 5 t&e 7uality is 7uite

"" : 38.2 6 minute 5 regular

T : 39. degrees using a6illary temperature


2/19

&ead :

#nspection : anemic con'uncti)a - - 5 sclera 'aundice - - 5 pupil iso*or ; ; 5 lig&t re!le6 ; ;


3/19

I.% E$amination S&pport

I.' Dia(nosis

Olecranon >ursitis

I.) *o+ernance

O2 3-4 liters minute

#0F+ 29 T


4/19

CHAPTER II

BURSITIS

+F#N#T#ON

>ursitis is t&e in!lammation or irritation o! t&e bursa. T&e bursa is a sac !illed %it& lubricating

!luid5 located bet%een tissues suc& as bone5 muscle5 tendons5 and s*in5 t&at decreases rubbing5

!riction5 and irritation.

/A@((

>ursitis is most o!ten caused by repetiti)e5 minor impact on t&e area5 or !rom a sudden5 more

serious in'ury. Age also plays a role. As tendons age t&ey are able to tolerate stress less5 are less

elastic5 and are easier to tear.

O)eruse or in'ury to t&e 'oint at %or* or play can also increase a persons ris* o! bursitis.

6amples o! &ig&-ris* acti)ities include gardening5 ra*ing5 carpentry5 s&o)eling5 painting5

scrubbing5 tennis5 gol!5 s*iing5 t&ro%ing5 and pitc&ing. #ncorrect posture at %or* or &ome and poor

stretc&ing or conditioning be!ore e6ercise can also lead to bursitis.

An abnormal or poorly placed bone or 'oint ,suc& as lengt& di!!erences in your legs or art&ritis

in a 'oint can put added stress on a bursa sac5 causing bursitis. (tress or in!lammation !rom ot&er

conditions5 suc& as r&eumatoid art&ritis5 gout5 psoriatic art&ritis5 t&yroid disorders5 or unusual

medication reactions may also increase a persons ris*. #n addition5 an in!ection can occasionally

lead to in!lammation o! a bursa#n!ection t&at causes bursitis tends to be in bursae t&at are nearer t&e sur!ace o! t&e s*in5 suc&

as t&ose near t&e elbo%. A cut on t&e s*in is an opportunity !or t&e bacteria to get in. Most &ealt&y

people %ould not be a!!ected by opportunistic bacteria trying to get in t&roug& t&e s*in. Ho%e)er5

people %it& %ea*ened immune systems5 suc& as t&ose %it& diabetes5 H#0A#+(5 /ancer

,recei)ing c&emot&erapyor radiot&erapy5 as %ell as people ta*ing steroids5 and &ea)y consumers

o! alco&ol.>ursitis is more common in adults5 especially in t&ose o)er 4 years o! age.

/$A((#F#/AT#ON

>ursitis is generally classi!ied based on t&e site o! in)ol)ement. 6amples include:

Housemaids *nee #n!lammation o! bursa on !ront o! t&e *nee


5/19

/lergymans *nee - #n!lammation o! bursa on !ront and 'ust belo% t&e *nee

>a*ers cyst - #n!lammation o! bursa 'ust be&ind t&e *nee

(tudents elbo% - #n!lammation o! bursa 'ust be&ind t&e elbo%

ump - #n!lammation o! bursa be&ind t&e &eel

(IM


6/19

coe6istent %it& supraspinatus tendinitis and partial- or complete-t&ic*ness tears o! t&e supraspinatus

tendon ,1 o! t&e 4 tendons comprising t&e rotator cu!!.K1L

Subscapular bursitis

(ubscapular bursae become in!lamed as a result o! abnormal bony structures or so!t-tissue

c&anges t&at a!!ect t&e mo)ement o! t&e scapula o)er t&e posterior c&est %all.

Olecranon bursitis

T&e more super!icial o! t&e 2 olecranon bursae commonly in)ol)ed in bursitis is predisposed

to direct trauma or cumulati)e microtrauma !rom acti)ities re7uiring !re7uent elbo% motion ,eg5

s%imming5 s*iing5 gymnastics5 and %eig&tli!ting. T&is type o! bursitis is o!ten recurrent.

1ower/e$tremity 0&rsitis

Bursitis of hip

#sc&iogluteal bursitis is associated %it& sedentary occupations and is caused by direct stress

on t&e bursa ,&ence t&e nic*name %ea)ers bottom.


7/19

Anserine ,pes anserinus bursitis is not usually associated %it& o)eruse but may occur in

patients %it& medial compartmental osteoart&ritis. /linically5 patients complain o! pain and

tenderness o)er t&e anteromedial *nee t&at is %orse %it& *nee !le6ion. T&is condition may be

con!used %it& medial meniscal pat&ology.K15 18L


8/19

Alt&oug& septic bursitis is not diagnosed solely on t&e basis o! clinical signs5 certain signs

tend to !a)or t&e diagnosis o! septic o)er sterile in!lammatory bursitis. #n particular5 patients %it&

septic bursitis may &a)e !e)er5 bursal %armt&5 tenderness t&at is more se)ere t&an in nonseptic

bursitis5 and associated peribursal cellulitis. =oint motion is typically preser)ed in septic bursitis5

%&ereas ot&er types o! bursitis are associated %it& limited range o! motion.

S&0acromial 0&rsitis

(ubacromial bursitis is !re7uently associated %it& supraspinatus tendinitis because

in!lammation e6tends !rom one structure to t&e ot&er. "epetiti)e acti)ities %it& an ele)ated arm

most !re7uently cause in!lammation o! t&e bursae. 6amples o! t&is include !re7uent pitc&ing o! a

baseball or li!ting luggage o)er&ead. $ess commonly5 a primary process5 suc& as r&eumatoid

art&ritis5 gout5 or tuberculosis5 may lead to bursitis.

ecause o! t&e &ig&er li*eli&ood o! in!ection5 some p&ysicians encourage aspiration and

analysis o! t&e bursa e)en %&en tenderness and eryt&ema are minimal.

/&ronic stress !rom repetiti)e !or%ard-leaning positions %it& pressure on t&e elbo%s is seen

in patients on long-term &emodialysis ,so-called dialysis elbo%5 in patients %it& c&ronic

obstructi)e lung disease5 in students5 and in t&ose %&ose occupation in)ol)es laying do%n carpet.

T&e term lunger elbo% &as been suggested to describe t&is a!!liction.

T&e most common nontraumatic cause o! olecranon bursitis is gout5 !ollo%ed by pseudogout5

r&eumatoid art&ritis5 and uremia.

&en in!lamed5 t&e bursa is e)ident as a !luctuant bulge posterior to t&e olecranon process

,see t&e images belo%.


9/19

slo%ly o)er %ee*s or mont&s it may be t&e only symptom present. Tenderness may occur anteriorly

belo% t&e middle o! t&e inguinal ligament and lateral to t&e !emoral artery. Occasionally5 a palpable

mass or )isible edema may be !ound lateral to t&e !emoral )essels.


10/19

T&e super!icial location o! t&e prepatellar bursa allo%s easy introduction o! microorganisms

and predisposes to septic art&ritis. T&ere!ore5 aspiration o! !luid to rule out in!ection is &ig&ly

recommended i! any clinical suspicion is present.

Inrapatellar 0&rsitis

(uper!icial in!rapatellar bursitis ,clergyman *nee is located more distally t&an prepatellarbursitis and is o!ten caused by !re7uent *neeling in an uprig&t position. #t can also be seen in gout or

syp&ilis. T&e di!!erential diagnosis includes Osgood-(c&latter disease. T&e deep in!rapatellar bursa

is less !re7uently in!lamed.

/linically5 t&e patient e6&ibits pain %it& !le6ion and e6tension at t&e e6tremes o! t&e range o!

motion. dema is located on bot& sides o! t&e patellar tendon and is associated %it& tenderness.

Anserine pes anserin&s3 0&rsitis

T&e anserine bursa separates t&e insertions o! t&e sartorius5 gracilis5 and semitendinosus

tendons !rom t&e tibial plateau. #t is so named because t&e edematous bursa5 restrained by t&ese 3tendons5 gi)es t&e appearance o! a gooses !oot ,pes anserinus. (ee t&e image belo%

$ocation o! anserine ,pes anserinus bursa on medial *nee. M/$Qmedial collateral ligament

An abnormal pull on any o! t&e 3 tendons or an abnormal gait predisposes to repetiti)e

!riction and to bursitis.


11/19

T&e calcaneal bursa can become in!lamed in patients %it& &eel spurs or in patients %it& poor-

!itting s&oes ,eg5 &ig& &eels. #n!lammation can occur secondarily !rom Ac&illes tendinitis5

especially in young at&letes.

lood studies: "outine laboratory blood %or* is generally not &elp!ul in t&e diagnosis o!

nonin!ectious bursitis. #n cases o! septic bursitis5 &o%e)er5 t&e leu*ocyte count and

eryt&rocyte sedimentation rate ,(" may be mildly to moderately ele)ated. >lood cultures

may be dra%n i! in!ection o! deep bursae is a concern. ("5 antinuclear antibody ,ANA5

r&eumatoid !actor ,"F5 and anti citric citrullinated peptide ,anti-//ursal !luid s&ould be

dra%n !or monosodium urate crystal determination5 cell count %it& di!!erential5 Gram stain5

and culture. / count o! -25S$ or &ig&er may be considered indicati)e o!

in!ection.

Gram stain and culture are per!ormed to identi!y any pat&ogens. T&e accuracy o! Gram

staining )aries considerably5 %it& sensiti)ities bet%een 1C and 1C. T&ere!ore5 !luid t&at &as a

&ig& >/ count but is negati)e on Gram staining is still considered suspicious !or in!ection.

le)ated protein le)el and reduced glucose le)el are associated %it& in!ection but are not

su!!iciently sensiti)e or speci!ic to be used in isolation. >ursal !luid culture is t&e conclusi)e test !or

diagnosis. /ulture in li7uid medium &as been s&o%n to be superior to culture on solid medium.

it& c&ronic or recurrent bursitis5 samples s&ould be sent !or acid-!ast staining and cultured on

special media !or mycobacteria5Brucella5 and algae.

Fluid s&ould also be e6amined !or crystals. Monosodium urate crystals are seen in gout

calcium pyrop&osp&ate crystals are seen in pseudogout c&olesterol crystals are seen in r&eumatoid

c&ylous bursitis and in a )ariety o! c&ronic e!!usions.

Art&rocentesis s&ould be per!ormed i! 'oint in)ol)ement is suspected


12/19

in!lammation. T&ey may also s&o% 'oint e!!usions. #n c&ronic bursitis5 t&e bursal %alls or

nearby tendons may be calci!ied and radiopa7ue.

>one scanning is not a sensiti)e test !or bursitis5 but it may be done in cases in %&ic& t&e

diagnosis is unclear to rule out ot&er causes o! pain.

>ecause o! t&e c&aracteristic clinical presentation o! bursitis5 magnetic resonance imaging,M"# and computed tomograp&y ,/T are usually unnecessary. M"# can be use!ul !or

delineating t&e anatomy o! t&e entire 'oint ,including ad'acent so!t tissues and depicting

bursal or prebursal !luid and associated abscessesK23L i! needed5 it is a )ery sensiti)e test !or

identi!ication o! bursitis. M"# is also &elp!ul in ruling out suspected solid tumors and

de!ining pat&ology !or possible surgical e6cision.

@ltrasonograp&y: @ltrasonograp&y is use!ul !or !urt&er imaging o! t&e bursa %&en t&e

diagnosis is uncertain. For diagnostic aspiration or treatment in'ections5 ultrasonograp&y

may be per!ormed to elucidate t&e structures and to guide procedures. T&e accuracy o!ultrasound-guided in'ections &as increased &o%e)er5 studies o! t&e e!!icacy o! ultrasound-

guided )ersus blinded in'ections pro)ide contro)ersial results.K24L #n addition5 ultrasound

studies distinguis& solid !rom cystic masses and are &elp!ul in detecting >a*er cysts

,popliteal bursitis %&en t&ere are e6tensi)e 'oint de!ormities. K115 2L >a*er cysts are o!ten

disco)ered incidentally %&en lo%er-e6tremity +oppler studies are done to rule out deep )ein

t&rombosis.

+#FF"NT#A$ +#AGNO(T#/

/ellulitis Gout and ursitis can be treated in a number o! %ays5 including:

A)oiding acti)ities t&at aggra)ate t&e problem

"esting t&e in'ured area

#cing t&e area t&e day o! t&e in'ury

Ta*ing o)er-t&e-counter anti-in!lammatory medicines

Most patients %it& bursitis are treated conser)ati)ely to reduce in!lammation. /onser)ati)e

treatment includes rest5 cold and &eat treatments5 ele)ation5 administration o! nonsteroidal anti-

in!lammatory drugs ,N(A#+s5 bursal aspiration5 and intrabursal steroid in'ections ,%it& or %it&out

local anest&etic agents.K19L


13/19

ecause o! t&e ris* o! ad&esi)e capsulitis5

s&oulders s&ould not be immobili?ed !or more t&an a !e% days. A!ter immobili?ation5 patients

s&ould begin graduated range-o!-motion e6ercises.


14/19

triamcinolone5 betamet&asone5 and de6amet&asone &a)e been used in t&is setting5 but no single

agent &as been !ound to be demonstrably superior. (teroids can be mi6ed in t&e same syringe %it&

lidocaine or bupi)acaine.

/orticosteroid in'ections can be per!ormed eit&er in t&e emergency department ,+ or in an

outpatient setting.K2D5 2LA 1.- to 4-inc& 2-gauge spinal needle may be used as a probe to determine

t&e points o! ma6imal tenderness in t&e a!!ected bursa. Typically5 a mi6 o! corticosteroid and local

anest&etic is in'ected into eac& tender site. An in'ection o! 2 mg or less o! corticosteroid s&ould be

used per lesion5 and no more t&an a total o! 4 mg o! corticosteroid s&ould be used. K15 145 28L

T&e potential complications o! intrabursal in'ections include t&e !ollo%ing:

#n!ection

>leeding

Allergy to in'ected agents

$ocal subcutaneous atrop&y ,Met&ylprednisolone is associated %it& t&e least !re7uent

de)elopment o! local subcutaneous atrop&y.


15/19

no signi!icant di!!erences bet%een &ig&er ,4 mg and lo%er ,2 mg doses o! triamcinolone

acetonide. T&ere!ore5 in general5 lo%er doses o! steroids s&ould be used initially.

6periences %it& platelet-ric& t&erapy ,


16/19

occasionally may be success!ully treated %it& conser)ati)e drainage and appropriate

antibiotics.Brucellabursitis is treated %it& e6cision o! bursae and administration o! tetracycline

%it& or %it&out ri!ampin

(urgical +rainage and 6cision

#n general5 bursitis is not treated surgically. Ho%e)er5 t&ere are some cases in %&ic& surgicalinter)entions suc& as t&e !ollo%ing are appropriate:

#ncision and drainage

6cision o! c&ronically in!lamed bursae

"emo)al o! underlying bony prominences

As a rule5 surgical inter)ention is reser)ed !or t&e !ollo%ing situations K3L:

Failure o! needle aspiration to drain t&e bursa ade7uately

>ursa site inaccessible to repeated needle aspirations

Abscess5 necrosis5 or sinus !ormation

Need !or e6ploration to assess t&e e6tent o! in!ection o! ad'acent structures

"ecurrent or re!ractory disease a!ter conser)ati)e treatment

(urgical release may be indicated %&en ad&esi)e bursitis de)elops t&at se)erely limits 'oint

motion. +uring surgery5 t&e ad&ered bursa is remo)ed5 and t&e contiguous tissues are released. K385 45

25 41L

#n t&e upper e6tremity5 subscapular bursitis can be caused by bony e6ostoses5 and surgery may

be needed to reduce t&ese structures. #n addition5 t&e association o! subacromial bursitis %it& rotator

cu!! impingement and tears is &ig&5 and surgical repair o! t&e tear may be indicated.

#n t&e lo%er e6tremity5 >a*ers cysts ,popliteal bursitis are o!ten remo)ed surgically. >e!ore

open e6cision5 art&roscopy s&ould be per!ormed to e)aluate !or intra-articular conditions. Most

cysts are approac&ed posteromedially t&roug& a &oc*ey-stic* incision.


17/19

An in!lamed s%ollen bursa may get in!ected secondarily. T&is is particularly common a!ter

attempts at aspiration o! t&e bursa %it& a syringe under unclean conditions. /&ances o! in!ection are

also &ig&er in diabetic patients.


18/19


19/19

SOURCES

http://www.nlm.nih.gov/medlineplus/ency/article/00041.htm

http://www.!etterhealth.vic.gov.au/!hcv"/!hcarticles.ns#/pages/$ursitis

http://emedicine.medscape.com/article/"14%%&&'medication

http://www.we!md.com/pain'management/arthritis'!ursitis

http://www.medicalnewstoday.com/articles/1%"1"0.php

http://www.we!md.com/pain'management/arthritis'!ursitis

&ttp:%%%.do*terbeda&&erryyud&a.com
http://www.nlm.nih.gov/medlineplus/ency/article/000419.htmhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Bursitishttp://emedicine.medscape.com/article/2145588-medicationhttp://www.webmd.com/pain-management/arthritis-bursitishttp://www.medicalnewstoday.com/articles/152120.phphttp://www.webmd.com/pain-management/arthritis-bursitishttp://www.dokterbedahherryyudha.com/2012/02/nephrolithiasis.htmlhttp://www.nlm.nih.gov/medlineplus/ency/article/000419.htmhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Bursitishttp://emedicine.medscape.com/article/2145588-medicationhttp://www.webmd.com/pain-management/arthritis-bursitishttp://www.medicalnewstoday.com/articles/152120.phphttp://www.webmd.com/pain-management/arthritis-bursitishttp://www.dokterbedahherryyudha.com/2012/02/nephrolithiasis.html

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Case Report Bursitis