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Zorluk: OrtaOrthopedic Surgery

A 52-year-old man presents to the emergency department with a 2-day history of progressive pain, swelling, and redness over his left knee. He works as a carpet layer and spends several hours a day kneeling. His temperature is 38.2°C (100.8°F), pulse is 92/min, and blood pressure is 128/82 mmHg. Physical examination reveals a fluctuant, erythematous, and exquisitely tender mass localized directly over the anterior aspect of the left patella. The overlying skin is warm to the touch. There is no bulging of the parapatellar recesses, and the patellar ballottement test is negative. The patient is able to achieve 130 degrees of passive knee flexion with minimal discomfort. Which of the following is the most appropriate immediate next step in management?

  1. A
    Arthrocentesis of the knee joint
  2. B
    Administration of empiric intravenous antibiotics
  3. Aspiration of the prepatellar bursaCevap
  4. D
    Magnetic resonance imaging of the left knee
  5. E
    Operative incision and drainage of the joint space

Cevap

The most appropriate immediate next step is aspiration of the prepatellar bursa.
The correct answer is aspiration of the prepatellar bursa. This patient's occupational history (carpet laying, requiring prolonged kneeling) and physical exam findings (localized anterior swelling, erythema, normal range of motion) are classic for acute prepatellar bursitis, commonly referred to as 'housemaid's knee'. The presence of a fever suggests a septic etiology, most frequently caused by Staphylococcus aureus. Diagnostic aspiration of the bursa is the essential next step to obtain fluid for cell count, Gram stain, and culture prior to starting empiric antibiotics. It is crucial to recognize that prepatellar bursitis is an extra-articular process; the preserved passive range of motion and negative patellar tap test rule out septic arthritis of the knee joint.

Adım Adım Çözüm

1
Analyze the patient's occupational history and physical examination findings.
The patient has localized anterior knee swelling, erythema, and fever, but normal passive range of motion and no joint effusion.
To differentiate between intra-articular pathology (like septic arthritis) and extra-articular pathology (like bursitis).
2
Formulate a clinical diagnosis based on the location and characteristics of the swelling.
The findings strongly indicate acute prepatellar bursitis, with fever suggesting it is septic.
The prepatellar bursa is superficially located anterior to the patella, which correlates perfectly with the patient's localized swelling and history of kneeling.
3
Determine the appropriate initial diagnostic and therapeutic intervention.
Bursal fluid aspiration must be performed to obtain fluid for Gram stain and culture.
Pathogen identification is essential before initiating empiric antibiotic therapy to ensure appropriate antimicrobial coverage.

Anahtar Kavram

Differentiating extra-articular septic bursitis from intra-articular septic arthritis based on physical exam (preserved range of motion and lack of effusion in bursitis), and prioritizing bedside fluid aspiration prior to antibiotic administration.
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Orthopedic Surgery

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