What is the appropriate treatment for a patient presenting to the Emergency Department (ED) with a right knee X-ray showing no acute fracture, maintained joint spaces, and trace joint effusion?

From the Guidelines

Based on the right knee X-ray findings showing no acute fracture, maintained joint spaces, and only trace joint effusion, I recommend conservative management with rest, ice, compression, and elevation (RICE therapy) for 48-72 hours, as well as over-the-counter pain medications such as acetaminophen (Tylenol) 500-1000mg every 6 hours as needed, as suggested by the most recent guidelines 1. Given the presence of trace joint effusion, which indicates a mild inflammatory response, it is essential to manage the pain and inflammation appropriately. The treatment approach should be tailored according to the patient's specific risk factors, level of pain intensity, and disability, as outlined in the EULAR recommendations 1. Key aspects of the management plan include:

• Rest, ice, compression, and elevation (RICE therapy) for 48-72 hours
• Over-the-counter pain medications such as acetaminophen (Tylenol) 500-1000mg every 6 hours as needed, not exceeding 4000mg daily
• Topical applications (NSAIDs, capsaicin) may be considered for additional pain relief, as they have clinical efficacy and are safe 1
• Gradually return to normal activities as pain allows, avoiding high-impact exercises until symptoms resolve completely
• Follow-up with the primary care provider if pain persists beyond 1-2 weeks, worsens significantly, or if new symptoms develop, such as increased swelling, redness, or inability to bear weight. It is also important to note that, according to the ACR Appropriateness Criteria 1, if the patient's symptoms persist or worsen, further imaging studies, such as an MRI, may be necessary to rule out occult fractures or internal derangement.

From the FDA Drug Label

Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acute gout Improvement in patients treated for rheumatoid arthritis was demonstrated by a reduction in joint swelling, a reduction in duration of morning stiffness, a reduction in disease activity as assessed by both the investigator and patient, and by increased mobility as demonstrated by a reduction in walking time In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease Naproxen may be used safely in combination with gold salts and/or corticosteroids; however, in controlled clinical trials, when added to the regimen of patients receiving corticosteroids, it did not appear to cause greater improvement over that seen with corticosteroids alone

Treatment with Naproxen

• The patient's right knee X-ray shows no acute fracture, maintained joint spaces, and trace joint effusion, which may indicate osteoarthritis or another condition that could be treated with naproxen.
• Key benefits of naproxen include reduction in joint pain or tenderness, increase in range of motion in knee joints, and increased mobility.
• Considering the patient's symptoms, naproxen could be a suitable treatment option to reduce pain and inflammation in the right knee.
• However, it is essential to follow the recommended dosage and monitor for potential side effects, as naproxen can cause gastrointestinal events, nervous system adverse effects, and other complications 2, 2.

From the Research

Treatment Options for Knee Pain

• The patient's right knee x-ray shows no acute fracture, maintained joint spaces, and trace joint effusion, indicating a non-severe injury 3.
• For acute mild to moderate pain, first-line treatment options include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) 3.
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries, which may be applicable to this case 3.
• The use of multimodal non-opioid analgesia, such as combining acetaminophen with NSAIDs, has been increasing and may be effective in reducing in-hospital complications 4.

Medication Considerations

• Acetaminophen is well tolerated, but lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 3.
• Nonselective NSAIDs are effective but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 3.
• Intravenous acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen, but its effect on postoperative outcomes in emergency hip fractures is unclear 5.

Treatment at the Emergency Department (ED)

• The patient's treatment at the ED should be tailored to their specific needs, including a review of treatment expectations and a plan for the time course of prescriptions 3.
• Adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 3.