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| CASE REPORT |
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| Year : 2020 | Volume
: 15
| Issue : 2 | Page : 300-302 |
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Bursitis of shoulder region and elbow – Subdeltoid-subacromial and olecranon bursitis ultrasonography and elastography imaging
Megha Manoj, Suresh V Phatak, Kaustubh Madurwar, Gulam Marfani
Department of Radio-diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| Date of Submission | 06-Feb-2020 |
| Date of Decision | 28-May-2020 |
| Date of Acceptance | 19-Jun-2020 |
| Date of Web Publication | 21-Dec-2020 |
Correspondence Address:
Dr. Suresh V Phatak
Department of Radio-diagnosis, JNMC, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_40_20
Bursitis involving the upper limb can present with swelling, pain and restriction of movements. Clinically, bursitis can mimic joint pathologies, and hence, it is important to differentiate it from the latter. Sonoelastography is an excellent initial and inexpensive imaging modality of choice for diagnosis.
Keywords: Bursitis, sonoelastography, sonography
How to cite this article:
Manoj M, Phatak SV, Madurwar K, Marfani G. Bursitis of shoulder region and elbow – Subdeltoid-subacromial and olecranon bursitis ultrasonography and elastography imaging. J Datta Meghe Inst Med Sci Univ 2020;15:300-2 |
| Introduction | |  |
A bursa is a small fluid-filled sac which helps in the smooth movement between two structures. Bursitis refers to the inflammation of these fluid-filled sacs found around joints. Its causes include overuse, injury, infection or any other inflammatory process such as rheumatoid arthritis. Symptoms of bursitis depend on the location of the bursae. In general, they present with pain and restriction of movements around joint. In cases where the bursa is situated more superficially, it can also present with a swelling. Several bursae are present in the upper limb, out of which two important ones are (1) subacromial-subdeltoid bursa and (2) olecranon bursa.
Subacromial-subdeltoid bursa is the largest bursa around the shoulder joint, and it lies between the acromion and the humeral head. It separates the supraspinatus tendon from the acromion and deltoid superiorly. It helps in the smooth movement of rotator cuff tendons and the long head of biceps. Normally, the bursa appears as a hypoechoic structure sandwiched between two echogenic lines which represent the peribursal fat tissue and is not >2 mm in thickness. Anteriorly, the bursa extends over the bicipital groove and medially up to the subcoracoid bursa. The posterior and lateral extends of the bursa are variable. In some cases, it can extend 3 cm beyond the greater tubercle laterally.[1] Subacromial bursitis is one of the most common findings in subacromial impingement syndrome.
Olecranon bursa is a small fluid-filled sac present between the skin and dorsal aspect of the olecranon process of the ulna. It helps the skin glide over the bone smoothly. Olecranon bursitis, also known as “swollen or Popeye elbow,” is the most common superficial bursitis in our body. It can occur due to inflammatory process, trauma, infection or chronic microtrauma.
| Case Reports | | |
Case 1
A 29-year-old male presented to the orthopedic outpatient department with complaints of left elbow swelling and pain following trauma to the elbow. On examination, there was a well-defined, tender, firm swelling on the dorsal aspect of the left elbow. He was referred to the radiology department for ultrasound examination of the swelling [Figure 1]. On sonography, there was a well-defined anechoic structure with internal debris on the dorsal aspect of the left elbow which showed minimal peripheral vascularity on Doppler. On elastography, the lesion showed blue-green-red (BGR) pattern (according to Tsukuba classification) [Figure 2]. | Figure 2: US image shows a well-defined anechoic structure with internal debris on the dorsal aspect of the left elbow which showed minimal peripheral vascularity on Doppler suggestive of olecranon bursitis. Sonoelastography shows the lesion that showed blue-green-red pattern
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Case 2
A 36-year-old diabetic male presented with right shoulder pain for 2 months with no significant history of trauma or fever. On examination, the patient was found to have difficulty in abducting the right shoulder joint. On sonography, there was a well-defined anechoic structure with internal debris between supraspinatus tendon and deltoid muscle measuring 12 mm in thickness and showed no vascularity on Doppler. On elastography, the lesion showed BGR pattern (according to Tsukuba classification) [Figure 3]. | Figure 3: US image shows a well-defined anechoic structure with internal debris between supraspinatus tendon and deltoid muscle measuring 12 mm in thickness which showed no vascularity on Doppler suggestive of subdeltoid-subacromial bursitis. Sonoelastography shows the lesion that showed blue-green-red pattern
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| Discussion | | |
Imaging modalities for bursa mainly include ultrasound and magnetic resonance imaging (MRI). On ultrasound examination, an inflamed bursa appears as a well-defined anechoic thickened structure with or without internal debris. On color Doppler, it can show peripheral vascularity. The diagnosis of bursitis would depend on its typical characteristics and location. The normal thickness of subdeltoid-subacromial bursa is <2 mm, and a thickness above this can indicate an underlying pathology. In cases of bursitis due to overuse, vascularity can be absent on Doppler.
MRI, being the gold standard for evaluation musculoskeletal system, is the investigation of choice for a definitive diagnosis of bursitis but is not done routinely because of its higher cost. On MRI, bursitis has a low signal on T1-weighted imaging and a high signal on T2-weighted imaging.[2]
Strain elastography has a high sensitivity and specificity and can be used to characterize soft-tissue lesions.[3] Tsukuba classification is a scoring system used to characterize lesions on strain elastography. The lesion can be a given a score between 1 and 5 or BGR depending on the elasticity of the lesion. A score of 1 or 2 can be considered benign, 3 can be probably benign, and 4 or 5 can be considered malignant. BGR sign is an artifactual three-layered appearance of a lesion, representing its cystic nature.[4],[5],[6]
| Conclusion | | |
Bursitis involving the upper limb is an important clinical condition causing a significant restriction of movement and pain. Ultrasound and elastography are highly accurate and inexpensive modalities in diagnosis and help in patient management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Springer Science & Business Media; 2007.  |
| 2. | Chaudhary K, Phatak SV. Olecranon bursitis – Ultrasonography and MR imaging: A case report. Int J Sci Res 2019. PRINT ISSN No 2277-8179 |
| 3. | Dawood MA, Ibrahim NM, Elsaeed HH, Hegazy NG. Diagnostic performance of sonoelastographic Tsukuba score and strain ratio in evaluation of breast masses. Egypt J Radiol Nucl Med 2018;49:265-71. |
| 4. | Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50. |
| 5. | Meshram P, Pawaskar A, Kekatpure A. 3D CT Scan-Based Study of Glenoid Morphology in Indian Population: Clinical Relevance in Design of Reverse Total Shoulder Arthroplasty. J Clin Orthop Trauma 2020. Available from: https://doi.org/10.1016/j.jcot.2020.03.001. [Last accessed on 2019 Dec 27]. |
| 6. | Sharma, Sanchit, Achintya D. Singh, Surendra K. Sharma, Madhavi Tripathi, Chandan J. Das, and Rajeev Kumar. Gallium-68 DOTA-NOC PET/CT as an Alternate Predictor of Disease Activity in Sarcoidosis. Nucl Med Commun 2018;39:768-8. Available from: https://doi.org/10.1097/MNM.0000000000000869. [Last accessed on 2019 Dec 27]. |
[Figure 1], [Figure 2], [Figure 3]
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