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Bursae and Bursitis of the Knee

- See:
      - Septic Knee:
      - Synovium of the Knee:

- Anatomy:
    - four bursae around knee are susecptible to and inflammatory response from direct or indirect trauma;
    - prepatellar bursae is most commonly affected area (housemaids knee);
    - may show significant degree of swelling;
    - two bursae are infrequently affected;
           - infrapatellar and deep patellar bursae;
           - when dx is in must also consider fat pad impingment syndrome versus bursitis;
    - fourth bursa:
           - deep to pes arserinus insertion;
           - rarely affected w/ bursitis (dx of exclusion)
           - first r/o chondral frx, meniscal tear, or osteonecrosis;

- Infrapatellar bursitis:
    - small deep subpatellar or infrapatellar bursa is located between tuberosity of tibia & patellar tendon and is separated from synovium of 
           the knee by a pad of fat;

- Prepatellar Bursitis:
    - traumatic prepatellar bursitis may be caused by acute injury such as fall directly on the patella or by recurrent minor injuries, such as 
          those that produce "housemaid's" knee;
    - pyogenic prepatellar bursitis is common, especially in children;
          - when bursae is large, swelling may be so pronounced that dx of pyogenic arthritis of knee joint may be mistakenly made;
          - this mistake must be avoided because if the knee joint is opened pyogenic arthritis will develop;
          - on other hand, if correct dx is made & bursa is drained properly, pyogenic arthritis is prevented;


- Management of Bursitis:
    - aspiration and injection of an appropriate drug;
    - traumatic bursitis will often respond favorably to aspiration & injection of an appropriate steroid preparation;
    - incision and drainage when an acute suppurative bursitis fails to respond to non surgical treatment;
    - excision of chronically infected and thickened bursae
    - removal of underlying bony promineces;

- Technique of Drainage:
    - approach of bursa thru two longitudinal incisions, one medial and one lateral, or thru a single transverse incision;
    - open bursa, evacuate its contents, and pack it loosely w/ petrolatum gauze or close it loosely over a drain as seems appropriate;
    - compression dressing should be applied after aspiration;

- After Treatment:
    - because cellulitis is always present, the extremity is immobilized in posterior splint, and appropriate antibiotics are given;
    - if gauze has been used to pack bursa, it is changed at least qod;
    - even w/ good drainage, sinuses often persist on one or both sides of joint;
           - joint must not be invaded since bursa does not communicate w/ it;
           - pt should be informed when first seen that complete excision of of bursa may be necessary if healing fails to occur after simple 
    - when walls of bursa are thickened from chronic inflammation, resecting entire bursa is usally easy, but when lesion is acute & 
           effusion is serous, excising the bursa completely may be impossible, yet enough may be excised to relieve symptoms;
           - occassionally fibrosis or synovial thickening w/ painful nodules requires excision of the bursae

The skin incision in the excision of the prepatellar bursa

Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm