What is the initial management for aseptic prepatellar bursitis in the emergency department?

Management of Aseptic Prepatellar Bursitis in the Emergency Department

Initial management of aseptic prepatellar bursitis in the emergency department should include rest, ice, compression, elevation (RICE), oral NSAIDs, and consideration of aspiration if the bursa is significantly distended.

Diagnosis and Assessment

• Prepatellar bursitis presents with pain, swelling, and inflammation over the anterior aspect of the knee, often resulting from chronic microtrauma (e.g., kneeling) or acute trauma 1
• Differentiate between septic and aseptic bursitis by assessing:
  • Presence of fever, extensive erythema, or significant warmth suggesting infection 1
  • History of recent trauma with skin break, which increases risk of infection 2
  • Occupational history, as jobs requiring kneeling predispose to this condition 2

Initial Management Protocol

Non-pharmacological Interventions

• Rest and activity modification to avoid pressure on the affected knee 1
• Ice application for 15-20 minutes several times daily to reduce inflammation 1
• Compression with elastic bandage to limit further fluid accumulation 1
• Elevation of the affected limb to reduce swelling 1
• Padding to protect the area from further trauma 1

Pharmacological Management

• NSAIDs are first-line therapy for pain and inflammation management 3
  • Naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 3
  • Initial total daily dose should not exceed 1250 mg, with subsequent daily doses not exceeding 1000 mg 3

Aspiration

• Consider aspiration for significantly distended, painful bursae to provide symptomatic relief 1
• Aspiration should be performed using sterile technique to avoid introducing infection 1
• Note: Routine aspiration of aseptic bursitis is generally not recommended due to the risk of iatrogenic septic bursitis 1

Special Considerations

When to Suspect Septic Bursitis

• If infection is suspected (fever, extensive erythema, significant warmth), bursal aspiration should be performed for:
  • Gram stain
  • Cell count
  • Culture
  • Crystal analysis (to rule out gout) 1

Indications for Antibiotics

• Antibiotics should only be initiated if septic bursitis is suspected 1
• Empiric coverage should target Staphylococcus aureus, the most common pathogen in septic bursitis 4, 5

Immobilization

• Consider immobilization with splinting for comfort and to reduce inflammation 2
• For particularly acute cases, immobilization may be beneficial 6

Follow-up and Disposition

• Provide clear discharge instructions including:
  • Continue RICE protocol at home
  • Proper dosing of prescribed NSAIDs
  • Warning signs of infection requiring return to medical care
  • Activity modifications to prevent recurrence 1
• Arrange follow-up within 1-2 weeks to assess response to treatment 1
• Consider referral to orthopedics or rheumatology if:
  • Symptoms persist despite 2-3 weeks of conservative management
  • Recurrent episodes of bursitis occur 1

Pitfalls and Caveats

• Avoid corticosteroid injections in the acute setting, especially if infection cannot be confidently ruled out 1
• Be aware that patients with occupations requiring kneeling have higher rates of recurrence and prolonged symptoms 2
• Recognize that chronic bursitis may require more aggressive management including surgical intervention if conservative measures fail 7
• Antibiotic treatment duration should be at least 14 days if septic bursitis is diagnosed, as shorter courses are associated with higher failure rates 5