What is the best course of action for an elderly patient with a swollen knee and inability to bear weight?

Immediate Management of Elderly Patient with Swollen Knee and Inability to Bear Weight

Obtain plain radiographs (anteroposterior and lateral views) of the knee immediately, as this elderly patient with inability to bear weight meets both Ottawa Knee Rule and Pittsburgh Decision Rule criteria for mandatory imaging to exclude fracture. 1

Initial Diagnostic Approach

Imaging Requirements

• Plain radiographs are the mandatory first-line imaging study for any elderly patient with acute knee trauma who cannot bear weight 1
• The patient meets multiple high-risk criteria:
  • Age >55 years (Ottawa Knee Rule criterion) 1
  • Age >50 years (Pittsburgh Decision Rule criterion) 1
  • Inability to take four weight-bearing steps (both Ottawa and Pittsburgh criteria) 1
• Obtain minimum two views: anteroposterior and lateral at 25-30 degrees of flexion 1
• A cross-table lateral view with horizontal beam enables visualization of lipohemarthrosis, which indicates intra-articular fracture 1

Critical Clinical Assessment Points

• Examine for gross deformity, palpable mass, or penetrating injury—these override clinical decision rules and mandate immediate imaging 1
• Check for isolated patellar tenderness or tenderness over the fibular head—additional Ottawa Rule criteria 1
• Assess ability to flex knee to 90 degrees—inability is another Ottawa criterion 1
• Look for significant ecchymosis, which may indicate quadriceps or patellar tendon rupture 2

Management Based on Radiographic Findings

If Fracture is Present

• Immediate orthopedic consultation for surgical evaluation 1
• Non-weight bearing status with appropriate immobilization 1

If No Fracture on Plain Films but High Clinical Suspicion

• Consider CT for occult fractures, particularly tibial plateau fractures which CT detects with 100% sensitivity versus 83% for radiographs 1
• MRI is the next appropriate study if internal derangement (meniscal tear, ligament injury) is suspected after negative radiographs 1

If No Fracture and Likely Osteoarthritis or Soft Tissue Injury

Immediate Interventions

• Intra-articular corticosteroid injection for moderate-to-severe pain with joint effusion 1, 3
• Provide assistive device (cane or walker) immediately to reduce joint loading and enable mobility 3

Pharmacological Management

• Start paracetamol up to 4 grams per 24 hours as first-line oral analgesic 1, 3
• Add topical NSAIDs before considering oral NSAIDs, as they have superior safety in elderly patients 1, 3
• If insufficient relief, prescribe oral NSAIDs or COX-2 inhibitors at lowest effective dose with mandatory proton pump inhibitor co-prescription 1, 3
• Avoid opioids unless NSAIDs are contraindicated or ineffective 3
• Do NOT prescribe glucosamine, chondroitin, or hyaluronic acid injections—these have no clinically important benefit 1

Essential Non-Pharmacological Interventions (Initiate Within Days)

• Refer to physical therapy for 12+ directly supervised sessions focusing on quadriceps strengthening 3
• Prescribe structured exercise program: quadriceps strengthening 2 days per week at moderate-to-vigorous intensity for 8-12 repetitions 3
• Add aerobic exercise (walking or cycling) 30-60 minutes daily at moderate intensity 3
• Programs lasting 8-12 weeks with 3-5 sessions weekly produce significant pain reduction 3
• If overweight, implement weight-loss program with explicit goals and regular follow-up 3
• Enroll in self-management program with education and coping skills training, which reduces healthcare costs by up to 80% 3

Critical Pitfalls to Avoid

• Never skip radiographs in elderly patients who cannot bear weight—clinical examination alone misses fractures 1
• Do not prescribe diuretics for knee swelling without determining the cause, as this leads to electrolyte imbalances and falls in elderly patients 4
• Do not refer for arthroscopic lavage/debridement unless there is clear mechanical locking from loose bodies 1
• Do not withhold exercise therapy based on age—elderly patients achieve similar gains as younger adults 3
• Physician judgment supersedes clinical guidelines when gross deformity, altered mental status, neuropathy, or multiple injuries are present 1