M71.019 Abscess of bursa, unspecified shoulder

Name of the Condition

• Abscess of bursa, unspecified shoulder

Summary

An abscess of the bursa, unspecified shoulder, is a localized collection of pus within the bursa of the shoulder, a small fluid-filled sac that reduces friction between tissues. This condition typically causes pain, swelling, and warmth at the affected site. The "unspecified shoulder" designation indicates the abscess is localized to the bursa in the shoulder region, without specifying left or right.

Causes

Abscesses of the shoulder bursa usually 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 foreign body reaction or sterile inflammation, are less frequent.

Risk Factors

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

Symptoms

• Localized pain, tenderness, or throbbing in the shoulder
• Swelling, redness, or warmth over the bursa
• Limited range of motion in the shoulder joint
• Possible fever or systemic signs if infection spreads
• Pus drainage if the abscess ruptures

Diagnosis

Diagnosis involves a physical examination to assess bursal swelling, warmth, and tenderness. Imaging (e.g., ultrasound or MRI) may be used to confirm the presence of an abscess and evaluate its extent. Aspiration of the bursa may be performed to identify the causative organism and guide treatment.

Treatment Options

Treatment typically includes antibiotic therapy to address bacterial infection, often with drainage of the abscess via needle aspiration or surgical incision. Pain management and rest of the affected shoulder are also recommended. In severe cases, surgical debridement may be necessary.

Prognosis and Follow-Up

With appropriate treatment, most shoulder bursal abscesses resolve without long-term complications. Follow-up care may involve monitoring for recurrence or residual symptoms. Patients with underlying conditions (e.g., immunocompromise) may require extended antibiotic therapy or additional interventions.

Complications

Untreated abscesses can lead to the spread of infection to surrounding tissues or systemic infection (sepsis). Chronic inflammation or scarring may result in persistent pain or limited shoulder mobility. Rarely, the abscess may rupture, causing further tissue damage.

Lifestyle & Prevention

• Avoid repetitive overhead motions or excessive pressure on the shoulder.
• Maintain good skin hygiene to prevent infections.
• Promptly treat minor shoulder injuries or skin wounds.
• Manage chronic conditions (e.g., diabetes) to reduce infection risk.

When to Seek Professional Help

Seek medical attention if shoulder pain is severe, worsening, or accompanied by fever, swelling, or pus drainage. Immediate care is needed if symptoms suggest spreading infection (e.g., red streaks, chills, or confusion).

Tips for Medical Coders

Document the shoulder location as "unspecified" when the left or right shoulder is not clearly identified. Ensure clinical notes support the absence of laterality to justify the unspecified designation. Verify that the abscess is localized to the bursa (not adjacent tissues) to align with the code’s specificity.