Is prednisone (corticosteroid) suitable for treating swelling due to injury?

Prednisone for Injury-Related Swelling: Not Recommended

Prednisone should generally be avoided for routine injury-related swelling, as major trauma guidelines specifically recommend against corticosteroid use in this setting. 1

Evidence Against Corticosteroids in Trauma

The Society of Critical Care Medicine and European Society of Intensive Care Medicine 2017 guidelines provide a conditional recommendation against the use of corticosteroids in major trauma, based on analysis of 19 trials involving over 12,000 patients. 1 Key findings include:

• No mortality benefit: Deaths occurred in 26.9% of corticosteroid-treated patients versus 23.4% in placebo groups (RR = 1.00,95% CI 0.89–1.13) 1
• No dose-response relationship: Neither low-dose nor high-dose corticosteroids showed survival advantage 1
• No safety advantage: While corticosteroids didn't increase bleeding or infection risk, they also provided no clinical benefit 1

When Corticosteroids May Be Considered

Complex Regional Pain Syndrome (CRPS)

If injury-related swelling progresses to CRPS (characterized by disproportionate pain, allodynia, temperature/color changes, and meets Budapest criteria), early prednisone treatment may be beneficial:

• Dosing: Prednisone 0.5-1.0 mg/kg daily tapered over 1-2 weeks 2
• Evidence: Case series demonstrate resolution of pain, swelling, and disability when treated early 3
• Caveat: This requires formal CRPS diagnosis, not simple post-injury swelling 3

Inflammatory Arthritis (Not Traumatic Swelling)

For confirmed inflammatory joint conditions (not acute injury):

• Mild symptoms: Start with NSAIDs (naproxen 500 mg BID or meloxicam 7.5-15 mg daily) for 4-6 weeks 4
• Moderate symptoms: Prednisone 10-20 mg daily if NSAIDs fail 4
• Severe symptoms: Prednisone 0.5-1 mg/kg daily 4

Critical Distinction: Trauma vs. Inflammation

The evidence clearly separates acute traumatic injury from inflammatory conditions:

• Traumatic swelling: Results from tissue necrosis, hemorrhage, and ischemia-reperfusion injury—corticosteroids do not improve outcomes 1
• Inflammatory arthritis: Characterized by morning stiffness >30-60 minutes, improvement with movement/heat, and response to anti-inflammatory agents 1, 4

Recommended Approach for Injury-Related Swelling

First-line treatment should be:

• Acetaminophen for pain control 4
• NSAIDs if inflammatory component suspected (naproxen 500 mg BID or meloxicam 7.5-15 mg daily) 4
• Ice, elevation, and rest using standard RICE protocol

Reserve corticosteroids only for:

• Documented CRPS development (requires Budapest criteria) 3
• Confirmed inflammatory arthritis (requires rheumatologic examination and inflammatory markers) 1, 4
• Specific trauma-associated critical illness with documented adrenal insufficiency 1

Important Caveats

Avoid the pitfall of prescribing prednisone for routine post-injury swelling simply because it's anti-inflammatory. The trauma literature demonstrates no benefit and potential for unnecessary side effects including hyperglycemia, HPA axis suppression after prolonged use, and bone loss. 1, 2

If prednisone is used for a legitimate indication (CRPS or inflammatory arthritis), always co-prescribe calcium 800-1000 mg/day and vitamin D 400-800 units/day from day one. 2, 5