M71.011 Abscess of bursa, right shoulder

Name of the Condition

• Abscess of bursa, right shoulder

Summary

An abscess of the bursa, right shoulder, is a localized collection of pus within the bursa of the right shoulder, resulting from infection or inflammation. This condition causes pain, swelling, and functional impairment at the affected site. Bursae are small fluid-filled sacs that reduce friction between tissues, and when infected, they can become inflamed and filled with purulent material.

Causes

Abscesses of the bursa typically result from bacterial infection, often introduced through direct trauma, skin breakdown, or spread from adjacent tissues. Staphylococcus aureus is a common causative organism. Non-infectious causes, such as chronic inflammation or foreign body reaction, may also lead to bursal abscess formation.

Risk Factors

• Recent injury or surgery near the right shoulder bursa
• Skin infections or open wounds in the vicinity
• Immunocompromised states (e.g., diabetes, HIV)
• Chronic inflammatory conditions (e.g., rheumatoid arthritis)
• Repetitive motion or pressure on the right shoulder

Symptoms

• Localized pain, swelling, and warmth over the right shoulder bursa
• Redness or erythema at the site
• Fever or systemic signs of infection
• Limited range of motion in the right shoulder
• Pus drainage if the abscess ruptures

Diagnosis

Diagnosis involves a physical examination to assess bursal characteristics, including tenderness, fluctuance, and warmth. Imaging (e.g., ultrasound) may confirm fluid collection. Aspiration of the bursa may be performed to identify the causative organism and guide treatment.

Treatment Options

Treatment typically includes antibiotic therapy to address the underlying infection. Surgical drainage may be necessary for large or persistent abscesses. Pain management and rest of the affected shoulder are also recommended.

Prognosis and Follow-Up

With appropriate treatment, most bursal abscesses resolve without long-term complications. Follow-up care may include monitoring for recurrence and assessing shoulder function. Physical therapy may be recommended to restore mobility.

Complications

Untreated abscesses can lead to spread of infection, sepsis, or chronic bursal damage. Rupture of the abscess may result in further tissue inflammation or systemic infection.

Lifestyle & Prevention

• Avoid repetitive overhead motions that strain the shoulder
• Maintain good skin hygiene to prevent infection
• Use protective gear during activities that risk shoulder injury
• Manage chronic conditions like diabetes to reduce infection risk

When to Seek Professional Help

Seek medical attention if you experience severe pain, fever, or signs of spreading infection (e.g., redness extending beyond the shoulder). Prompt care is important to prevent complications.

Tips for Medical Coders

Document the specific location (right shoulder) and confirm the presence of a bursal abscess. Ensure clinical documentation supports the diagnosis and any associated procedures, such as drainage or aspiration.