Management of Patient with Multiple Contusions, Edema, Skin Irritation, and Osteoarthritis

Diagnostic Evaluation

The American College of Radiology recommends obtaining AP, lateral, and oblique projections of the wrist/hand to rule out hidden fractures given significant edema and extensive hematomas 2
Vascular and neurological evaluation should be performed to rule out compartment syndrome or nerve compression due to marked edema, examining distal pulses, capillary refill, sensation, and motor function 2
Laboratory tests, including complete blood count, prothrombin time (PT), partial thromboplastin time (PTT), and platelet count, should be ordered to evaluate coagulopathy or medication-induced ecchymosis, especially if the patient is using anticoagulants 1

The American College of Rheumatology recommends a supervised exercise program, including strengthening and low-impact aerobic exercises, for at least 30 minutes most days, adapted to the patient's functional capacity 1, 3
Weight loss is recommended if the patient is overweight or obese, aiming for a 5-10% reduction in body weight through diet and exercise, which can significantly improve pain and function 1, 3
Assistive devices, such as a cane in the contralateral hand, should be considered to reduce load on the affected knee 4
Appropriate footwear with a wide toe box and adequate support should be recommended to minimize joint load 4

Topical NSAIDs (e.g., diclofenac 2%) are recommended as first-line treatment, applied 2 times a day to clean, dry skin 1, 3
Acetaminophen oral is recommended as second-line treatment, up to 3,000-4,000 mg/day, ensuring the patient is not taking other acetaminophen-containing medications 1, 3
Oral NSAIDs should be used at the lowest effective dose for the shortest duration possible, considering cardiovascular and gastrointestinal risks 1, 3

Intra-articular corticosteroid injections are indicated for acute pain flares, especially with joint effusion, with benefits typically lasting up to 3 months 1
The frequency of injections should be limited to 3-4 per year 1
Blood glucose monitoring is necessary in diabetic patients after injection 1

Total knee arthroplasty (TKA) should be considered for the left knee given the bone-on-bone contact in the medial compartment, medial subluxation, and varus deformity, if symptoms are severe and do not respond to conservative management 1
Preoperative optimization is essential, including control of diabetes, hypertension, and hyperlipidemia 1

Structured education programs should be implemented, teaching the patient about their condition, joint protection techniques, and coping strategies 4, 3
Activity modification should be taught, including energy conservation and joint protection techniques 4, 3

Short-term evaluation (1-2 weeks) should assess edema of the wrist, skin lesion of the knee, and initial response to treatment 2
Medium-term evaluation (4-6 weeks) should assess response to topical NSAIDs, progress in physical therapy, and need to escalate treatment 1, 3
Long-term evaluation (3-6 months) should consider surgical options if there is no significant improvement with optimal conservative management 1