What is the management plan for a patient with traumatic bursitis and increasing effusion in the knee?

Management of Traumatic Bursitis with Increasing Knee Effusion

The optimal management for traumatic bursitis with increasing knee effusion includes aspiration of the effusion, NSAID therapy, rest, and close monitoring for signs of infection or compartment syndrome.

Initial Assessment

When evaluating a patient with traumatic bursitis and increasing knee effusion, focus on:

• Extent of effusion (size, tension, rate of accumulation)
• Signs of infection (erythema, warmth, fever)
• Neurovascular status of the limb
• Pain level and functional limitation
• Mechanism of injury and time since trauma

Diagnostic Approach

1. Physical examination:

   • Assess for fluctuance, warmth, erythema
   • Evaluate range of motion
   • Check neurovascular status
   • Measure compartment tension if concerning for compartment syndrome

2. Imaging:

   • Ultrasound is highly sensitive for detecting and characterizing joint effusions 1
   • Plain radiographs to rule out fracture
   • Consider MRI if concerned about internal derangement

3. Joint aspiration:

   • Essential for both diagnostic and therapeutic purposes
   • Analyze fluid for cell count, crystals, Gram stain, and culture
   • Helps differentiate between inflammatory, infectious, and hemorrhagic effusions 1

Treatment Algorithm

Step 1: Determine if Septic Bursitis is Present

If any of the following are present, treat as potential septic bursitis:

• Fever
• Significant erythema and warmth
• Purulent aspirate
• WBC count >3000 cells/mm³ in aspirate 2

Step 2: Management Based on Classification

For Non-Septic Traumatic Bursitis:

1. Aspiration of the effusion:

   • Provides immediate symptomatic relief
   • May need to be repeated if reaccumulation occurs 3

2. Anti-inflammatory therapy:

   • NSAIDs (naproxen 500mg twice daily) 4
   • Consider short course of oral prednisone for significant inflammation 5

3. Rest and activity modification:

   • Avoid activities that worsen symptoms
   • Elevate the affected limb

4. Compression and ice:

   • Apply compression wrap after aspiration
   • Ice for 20 minutes several times daily

5. Avoid corticosteroid injection:

   • Despite rapid relief, intrabursal steroid injections have high complication rates including infection (12%), skin atrophy (20%), and chronic local pain (28%) 6

For Septic Traumatic Bursitis:

1. Aspiration of purulent fluid:

   • May need repeated aspirations
   • Send for culture and sensitivity

2. Antibiotic therapy:

   • Empiric coverage for Staphylococcus aureus (most common pathogen)
   • Adjust based on culture results
   • Prophylactic antibiotics significantly reduce infection risk (p=0.04) 7

3. Close monitoring:

   • Follow-up within 24-48 hours
   • Consider hospitalization if severe or unresponsive to initial treatment

4. Surgical intervention:

   • Indicated for refractory cases
   • Bursectomy may be necessary (performed in 83.7% of cases in one large series) 7

Step 3: Monitor for Complications

• Compartment syndrome: Assess for pain with passive stretch, paresthesia, and paresis (early signs); pulselessness and pallor are late signs 8
• Infection: Monitor for increasing pain, erythema, fever
• Chronic bursitis: Follow for persistent effusion despite treatment

Follow-up Recommendations

• Reassess within 24-48 hours for septic bursitis
• Reassess within 3-5 days for non-septic bursitis
• Instruct patient to return sooner if:
  • Increasing pain
  • Fever
  • Spreading redness
  • Numbness or tingling
  • Significant increase in swelling

Pitfalls and Caveats

1. Don't miss compartment syndrome: Pain out of proportion to injury, pain with passive stretch, and paresthesia are early warning signs 8

2. Don't assume all traumatic bursitis is non-septic: Up to one-third of olecranon bursitis cases are septic, and trauma can precipitate both septic and non-septic bursitis 3

3. Avoid corticosteroid injections: Despite providing rapid relief, they carry significant risks of complications including infection, skin atrophy, and chronic pain 6

4. Don't underestimate recovery time: Complete recovery from septic bursitis can take months 3

5. Consider concomitant injuries: Present in 41% of cases, though they don't significantly influence complication rates (p=0.367) 7