Bursas are synovium-lined, sac-like
structures located throughout the body between skin and tendon or tendon and
bone (1,2). The main function of bursa is to reduce the friction between areas
of movement and some common locations are the shoulder, knee, hip, and elbow
(1). When these areas become swollen or inflamed it is known as bursitis.
During this abnormality the bursa will enlarge with fluid causing any movement
against or direct pressure upon the area to produce pain for the patient (2).
There are many causes of bursitis that
one should be aware of, five of which are prolonged pressure, trauma, sepsis,
autoimmune conditions, and idiopathic origins. Prolonged pressure is when the
bursa is stressed between a hard surface and bony prominence. Examples of this
prolonged pressure include over-use of the area with repetitive motions,
frequently resting one’s elbow on their desk, and working on one’s knees
without adequate padding. Traumatic bursitis is caused when direct pressure is applied
to the bursa, often unknowingly as it may have seemed benign at the time (2). Traumatic
bursitis does put the patient at risk of developing septic bursitis, often
difficult to distinguish against aseptic bursitis, which is most induced by
invasive procedures (2,3). Staphylococcus aureus causes roughly 80% of
septic bursitis through what is believed to be a direct inoculation, instead of
a hematogenous route due to the poor blood flow seen to bursas (4). Bursitis
can also be caused by autoimmune conditions such as rheumatoid arthritis,
osteoarthritis, systemic lupus erythematosus, scleroderma, spondyloarthropathy,
and gout. The last common cause of bursitis is idiopathic in origin (2).
Bursitis can be broken up further to
acute bursitis and chronic bursitis. Acute bursitis is typically caused by trauma,
infection, or crystalline joint disease resulting in pain on palpation of the
bursa as well as a decrease in range of motion that is secondary to pain. Whereas
chronic bursitis is typically caused by inflammatory arthropathies, repetitive
motions, or microtraumas most often causing painless swelling and thickening of
the bursa. Examination of the skin is an important distinguishing factor for
acute and chronic bursitis as trauma, erythema, and warmth should all be
evaluated to make a proper diagnosis (2).
Diagnosis of many types of bursitis
can be made clinically without further studies, however in the case of trauma,
concern for foreign bodies, or fractures imaging can play an important role in
diagnosis. Basic plain film imaging can be used when evaluating a superficial
bursa however, for a deeper bursa MRI and ultrasound can be used (1).
Ultrasound will also provide the added benefit of showing real-time images to
observe changes in active and passive movements (2). When evaluating an
inflamed bursa, aspiration is a critical tool to distinguish between septic and
aseptic bursitis as the aspirated fluid should be sent for a basic cell count
and cell cultures (3).
Treatment for bursitis depends on the
type and causative agent as most bursitis will heal on their own without
intervention. To combat the patient’s pain, bursitis can be treated with a
conservative treatment plan involving rest, ice, compression, and elevation as
well as NSAIDS and/or acetaminophen for pain (2). With deeper bursitis
corticosteroid injections can provide symptomatic relief however, this course
of treatment is not recommended for superficial bursa and can delay the
diagnosis of another condition such as a tear. Physical therapy is another
important treatment method to strengthen the muscles that support the area
around the bursa (2). For septic bursitis the typical course of treatment is oral
antibiotics as an outpatient but systemic IV antibiotics may be needed if signs
of widespread sepsis are present (4). The last line of treatment is surgery
which is most often used only as a last resort when all other conservative
treatment methods fail (2).
References
1.Chatra PS. Bursae around the knee joints. Indian J Radiol Imaging. 2012 Jan;22(1):27-30. doi: 10.4103/0971-3026.95400. PMID: 22623812; PMCID: PMC3354353.
2.Williams CH, Jamal Z, Sternard BT. Bursitis. [Updated 2021 Aug 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513340/
3.Aaron, Daniel L. MD; Patel, Amar MD; Kayiaros, Stephen MD; Calfee, Ryan MD Four Common Types of Bursitis: Diagnosis and Management, American Academy of Orthopaedic Surgeon: June 2011 - Volume 19 - Issue 6 - p 359-367
4.Cea-Pereiro JC, Garcia-Meijide J, Mera-Varela A, Gomez-Reino JJ. A comparison between septic bursitis caused by Staphylococcus aureus and those caused by other organisms. Clin Rheumatol. 2001;20(1):10-4. doi: 10.1007/s100670170096. PMID: 11254233.
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/
The reverse pivot shift test helps to diagnose acute or
chronic posterolateral instability of the knee. A significantly positive
reverse pivot shift test suggests that the PCL, the LCL, the arcuate complex,
and the popliteal fibular ligament are all torn. The reverse pivot shift test
begins with the patient supine with the knee in 900 flexion. Valgus
stress is then applied to the knee with an external rotation force. Bring the
knee from 90o of flexion to full extension. The tibia reduces from a
posterior subluxed position at about 20o of flexion. A shift and
reduction of the lateral tibial plateau can be felt as it moves anteriorly from
a posteriorly subluxed position. This is called the reverse pivot shift because
shift of the lateral tibial plateau occurs in the opposite direction of the
true pivot shift (seen in ACL tears). If the tibia is posterolaterally
subluxed, the iliotibial band will reduce the knee as the IT band transitions
from a flexor to extensor of the knee. It is very important to compare this
test to the contralateral knee. The pivot shift test indicates an ACL tear. The
reverse pivot shift test indicates posterolateral instability of the knee.
Posterolateral corner injury includes the LCL, popliteal fibular ligament,
arcuate complex, and the lateral capsule.
The anterior cruciate ligament is located in the front of
the knee. Rupture of the anterior cruciate ligament (ACL) is a condition
commonly seen in sports usually due to a non-contact pivoting injury. The Pivot
Shift test is a specific test for ACL deficient knee (ACL injury). Pivot shift
is pathognomonic for an ACL tear and is best demonstrated in a chronic setting.
Lachman’s test is the most sensitive examination test for ACL injury. o of flexion. The anteromedial bundle is
tight in flexion, and it increases anterior translation at 90o of
flexion. The Lachman’s test is the most sensitive test especially in acute
settings, and the examiner will find no end point with anterior translation of
the tibia. In an acute setting, physical examination can be difficult or
limited due to pain. With the Pivot shift test, the patient must be completely
relaxed, and the test is helpful in chronic situations especially if the
patient complains of the knee giving way.
In the Pivot shift, the knee subluxes
in extension and reduces at 20-30 degrees of flexion. The Pivot shift
correlates closely with patient satisfaction of their reconstructed knee. It is
a measure of functional instability following ACL reconstruction. Vertical
femoral tunnel placement will cause rotational instability seen as a positive
pivot shift, and the malposition of the bone tunnel will be seen in an AP view
x-ray of the knee. The 9 or 10 o’clock position is better than the 12 o’clock
position; the vertical position is bad. The patient with an ACL injury usually
has a non-contact pivoting injury event with an awkward landing, feeling a
“pop” sensation, or immediate swelling. Aspiration usually shows blood in the
knee which proves a 75% chance of ACL tear when you aspirate blood from the
knee. Patients will also exhibit a positive Lachman’s test which may be hard to
examine because of the pain. Aspiration of the knee may make the examination
easier. MRI of the knee joint will show the hematoma, and it may show bone
lesions or bruising in the typical location which is characteristic with tears
of the ACL. These injuries are typically located at the middle of the femoral
condyle and posterior part of the tibia laterally. You may find a triple injury
within the MRI (O’Donoghue’s Unhappy Triad). The O’Donoghue’s Unhappy Triad
include an anterior cruciate ligament (ACL) injury, a medial cruciate ligament
(MCL) injury, and a lateral meniscus injury. In chronic ACL tears, the posterior
horn of the medial meniscus is the most commonly injured structure. In acute
ACL tear, send the patient for therapy for range of motion, brace the patient
and allow the MCL to heal and reconstruct the ACL later if needed. Patients
should do stress hamstring therapy in ACL tears. The patient will probably
complain of instability immediately or later on.The tibia can be pulled forward more than
normal (anterior translation). The examiner will have a sense of increased
movement and lack of a solid end point. For the pivot shift test, the patient
should be lying supine and totally relaxed. With pivot shift, the knee is in
the subluxed position when the knee is in full extension. The pivot shift
starts with extension of the knee and you can feel a “clunk” at 20-30 degrees
of flexion. To perform, hold the knee in full extension then add valgus force
plus internal rotation of the tibia to increase the rotational instability of
the knee. Then take the knee into flexion. A palpable clunk is very specific of
an ACL tear. The iliotibial band will reduce the tibia and create the clunk on
the outside of the knee. Always compare with the other side. The ACL prevents
anterior translation of the tibia. It is a secondary restraint to tibial
rotation and varus and valgus stress. The ACL consists of two bundles: the posterolateral
bundle and the anteromedial bundle. The posterolateral bundle prevents pivot
shift, contributes to rotational stability, prevents internal rotation of the
tibia with the knee in near extension, and increases the anterior translation
and tibial rotation at 30
The ACL
keeps the tibia from sliding out in front of the femur and provides rotational
stability to the knee. Rupture of the ACL causes anterolateral rotatory
instability. The tibia moves anterolaterally in extension; however, when you
flex the knee, the IT band becomes a flexor of the knee. The IT band pulls back
and reduces the tibia. The pivot shift test goes from extension (tibia
subluxed) to flexion, with the tibia reduced by the iliotibial band. Both the
Lachman’s tests and the Pivot shift test are associated with 20-30 degrees of
knee flexion. The Lachman’s test starts at 20-30 degrees of flexion. With the
Pivot shift test, you feel the clunk at 20-30 degrees of flexion. 20-30 degrees
of flexion is important for examination of the ACL. For the Lachman’s test, the
femur is stabilized with one hand and the other hand pulls the tibia anteriorly
and posteriorly against the femur.
The anterior tibial artery is a branch of the popliteal
artery (posterior aspect of knee), which divides into the anterior tibial
artery and the posterior tibial artery (posterior). The anterior tibial artery
is a branch of the popliteal artery (posterior aspect of the knee), which
divides into the anterior tibial artery and the posterior tibial artery
(posterior). Sometimes the two divisions are called the anterior tibial artery
and the tibio-fibular trunk. th area of the anterior fibula. Then the extensor hallucis longus
muscle appears, so the anterior tibial artery lies between the tibialis
anterior muscle and the extensor hallucis longus muscle. The extensor hallucis
longus muscle arises from the middle 2/4th area of the anterior
fibula. The extensor hallucis longus then crosses the leg medially to take a
position in the medial side. The big toe is definitely medial, so the extensor
hallucis longus will go towards the big toe and become medial. The other toes
are lateral, so the extensor digitorum longus will be inserted laterally and
the anterior tibial artery will then be between these two muscles in the distal
part of the leg and in front of the ankle. When the extensor hallucis longus
tendon crosses the leg to go medially, it then crosses the anterior tibial
artery. At this point, the anterior tibial artery is between the extensor
hallucis longus and the extensor digitorum longus tendons. At the level of the
ankle joint, this is how we remember the arrangement of the anterior ankle
structures. Tom Has a Very Nice Dog:Tibialis anterior,
extensor Hallucis longus, Vessels, Nerve, extensor Digitorum
longus. This is only good to remember the structures in the distal portion of the
tibia in front of the ankle. This does not work proximally, and this does not
work for the structures in the middle third of the tibia. Extensor hallicus
longus tendon is medial. Anterior tibial artery is lateral. After the anterior
tibial artery passes underneath the extensor retinaculum, the artery is then
called the dorsalis pedis, distally. The deep peroneal nerve pierces the intermuscular
septum to enter the anterior compartment and goes through the substance of the
extensor digitorum longus muscle. of retractors in the posterior part of the
proximal tibia to avoid damage to any of these branches of the popliteal artery
since the bifurcation of the popliteal artery is in this area.
The relationship between the anterior tibial
artery and the deep peroneal nerve changes according to the location. Proximally
the nerve is lateral, then the nerve comes in front of the artery, finally the
nerve stays lateral, distally. CTA around the knee can be done for dislocations
or severe fractures around the knee area. At this level of the distal femur,
you can see the popliteal artery. At the level of the proximal part of the leg,
you can see the three branches of the popliteal artery: anterior tibial artery,
posterior tibial artery, and peroneal artery. Be careful during placement. The anterior tibial artery arises just below the
popliteus muscle. The anterior tibial artery pierces the interosseous membrane
to enter into the extensor compartment or anterior compartment of the leg. The anterior
tibial artery gives the anterior and posterior tibial recurrent arteries. The anterior
tibial recurrent artery is the one that can be injured from tibial tubercle
fracture in children, which can cause compartment syndrome of the leg. The artery
then runs proximally between the tibialis anterior medially and the extensor
digitorum longus laterally. The extensor digitorum longus arises from the upper
3/4
Patellar fractures can involve different topic, and I am
going to try and highlight the important points related to patellar fractures.
The medial patellofemoral ligament is the primary stabilizer of the patella, so
when the patella dislocates, you will have an injury to that ligament and also
an injury to the medial patellar facet articulation cartilage or an
osteochondral fragment. In addition to the medial patellar facet injury, you
will get a lateral femoral condyle injury. Bipartite patella occurs in about 8%
of the population. It could be bilateral in about 50%, and it usually occurs in
the superolateral aspect of the patella. You should observe it and not fix it.
It is not an acute fracture that may need excision or lateral retinacular
release. It can occur in children between 8-10 years old. It is a rare
condition. The patient will be unable to do straight leg raising, so you
suspect that the extensor mechanism is injured. The patient may have a high
riding patella on x-ray with a palpable gap when you examine the patient. The
x-ray may show small flecks of bone as the patellar tendon avulses with a
portion of the distal pole of the patella. Sometimes the bony injury is so
small that the condition can be missed. You should have a high index of suspicion.
You may need to get an MRI to confirm diagnosis. The treatment is usually ORIF
if the fracture is displaced.
The patella is a large sesamoid bone. The quadriceps muscle
is inserted at the proximal pole and the distal pole gives attachment to the
patellar tendon. The patella is triangular in shape. The proximal 3/4 of the
patella is covered with cartilage, however the distal 25% of the patella is not
covered with cartilage. The patella increases the power of the extensor
mechanism by about 50% because it displaces the extensor mechanism anteriorly,
and that will increase the moment arm.
Transverse fractures of the patella can be non-displaced or
displaced. The patella can be pulled apart by the attached quadriceps tendon.
The patient will be unable to do active extension of the knee. Upper or lower
pole fractures of the patella are fractures at the site of attachment of the
patellar tendon. Comminuted fractures of the patella can be non-displaced or
displaced. Comminuted fractures have multiple pieces, are very unstable, and
are difficult to fix. Vertical fractures of the patella are the most common,
and they are stable and nondisplaced. Osteochondral fractures are small fractures of the patella usually associated with acute dislocation of
the patella.
In examination, you may feel a palpable gap. The area of the
knee is usually swollen. The patient will be unable to do straight leg raise.
The lateral view of the knee is the best view to see the fracture. 2-3 mm of
displacement will probably mean that the patient will need surgery.
If you think that the patient’s extensor mechanism is
intact, and the patient is able to do straight leg raise, and the fracture is
nondisplaced or minimally displaced, it is usually a transverse fracture in
this situation, then immobilize the knee straight in a hinged knee brace for
4-6 weeks with weight bearing as tolerated. Sometimes the patient cannot move
the knee because of the pan and injection of lidocaine inside the knee can help
to assess the integrity of the extensor mechanism. If the patient has a total
knee with 2mm displacement of the patella, and the extensor mechanism is
intact, then the patient will be treated conservatively in a brace or in a knee
immobilizer (no surgery).
Indication for surgery is a displaced patellar fracture and
the inability to do straight leg raising.
First, preserve the patella (if
possible). The tension band fixation technique is the gold standard for the
treatment of displaced patellar fractures (the fracture is usually a transverse
fracture), and the tension band technique is the one that gives us the most
complications. The first step in the tension band technique is to reduce the
fracture with reduction clamps. Next, at least two K-wires are placed across
the fracture. An anterior tension band is applied, organized in a Figure-8
pattern. You need to put the Figure-8 tension band wire close to the patella
superiorly and not far away from the patella because that may cause construct
instability and fracture displacement. A second wire may be placed
circumferentially around the patella. Bending the K-wires from both ends may
decrease migration of the wires and decrease the complications. The wire that
is bent at both ends may be difficult to remove. Tension band fixation technique
may be done with K-wires or also with cannulated screws (through the cannulated
screws, you place the wires). It does not matter if you have an open or closed
fracture, you treat it the same way. When you place K-wires, it means
symptomatic hardware and thus a secondary reoperation. It was found that the
longitudinal screws and the tension band wires are a more superior fixation.
The tension band construct when performed correctly will provide absolute
stability and will convert the tension forces from the muscle pull into
compression forces at the articular surface. You want to have anatomic
reduction and stable fixation; don’t judge the reduction by what you see at the
surface of the fracture. Try to see and feel the joint if you can. Check the
x-rays carefully. The surface of the patella may be well reduced, however, the
joint may be distracted or displaced. If you tighten the cerclage wire
aggressively, you may have a good looking surface, but you may have a
distracted join. After you fix the patella, you will do a range of motion of
the knee before closure and give the patient a hinged knee brace, locked into
extension with weight-bearing as tolerated. Weight-bearing is controversial.
Some people start weight-bearing early, and some people start weight-bearing
after 4-6 weeks. A can may be helpful to the patient. You will begin active
flexion at 2-3 weeks (patient will lie prone, flexing and extending the knee).
When the patient is prone, it avoids active knee extension and avoids excessive
stress on the fracture site. At 6 weeks, you can unlock the brace and start
moving the knee, gradually increasing the flexion.
If the patellar fracture is comminuted, you can use the
peripatellar circumferential wire loop fixation, which is commonly used as an
addition to other methods of fixation. You can also use a plate fixation
utilizing a low profile implant and providing stable fixation. This technique
is becoming more popular.
You can also excise the patella partially or completely. In
a partial patellectomy, the distal pole is extra-articular, and if it is
severely comminuted and less than 40% of the patella, then you can excise it
(in general, you would like to preserve the patella). If you can’t preserve the
patella and ORIF is not possible, then do partial patellectomy and preserve the
largest piece. Partial patellectomy may be necessary, but open reduction and
internal fixation (if possible) is associated with a better outcome. You will
do the partial patellectomy in several comminuted inferior pole fractures. You
will do medial and lateral retinacular repair, and a poor outcome may occur
with removal of more than 40% of the patella. Total patellectomy will be done
when the fractured patella cannot be fixed. Total patellectomy can cause
extensor lag and loss of the extensor strength. The quadriceps torque is
reduced by about 50%.
Symptomatic hardware and knee pain is the most common
complication after patellar fracture fixation, especially if you use the
tension band technique. It requires implant removal in about 50% of the time.
This complication will include the hardware migration. Failure after patellar
fracture fixation occurs in about 20% of the time due to increasing age,
fixation with wires, technical errors and noncompliance.
