Immobilization and Activity
›Nonoperative pathway
›Indications
›Intact extensor mechanism
›Nondisplaced or minimally displaced fracture pattern
›Immobilization in full extension
›Knee immobilizer or cylinder cast based on swelling and compliance
›Skin checks daily
›Weight bearing plan
›Weight bearing as tolerated in extension for stable patterns
›Non weight bearing if uncertain stability or severe pain
›Early motion plan with orthopedics
›Progressive range of motion after initial immobilization period per specialist plan
›Multimodal analgesia
›Acetaminophen
›1000 mg PO every 6 to 8 hours
›Maximum 3000 mg per day in most adults
›Lower maximum in chronic liver disease and heavy alcohol use
›Ibuprofen
›400 mg PO every 6 to 8 hours
›Maximum 2400 mg per day
›Avoid in significant renal disease and active GI bleeding
›Naproxen
›500 mg PO once then 250 mg PO every 6 to 8 hours
›Maximum 1000 mg per day
›Avoid in third trimester pregnancy
›Ketorolac
›15 mg IV once
›Avoid in renal impairment and high bleeding risk
›Avoid repeated dosing without clear indication
›Oxycodone
›5 mg PO every 6 hours as needed
›Short course and lowest effective dose
›Avoid with significant sedation risk and concomitant CNS depressants
›Hydromorphone
›0.5 mg IV every 2 to 3 hours as needed
›Continuous monitoring if repeated dosing
›Use caution in older adults and sleep apnea
Hemarthrosis and Procedural Options
›Effusion management
›Symptomatic hemarthrosis
›If severe pain from tense effusion then ultrasound guided arthrocentesis consideration
›Avoid aspiration through overlying cellulitis or open wound
›Local anesthesia options
›Lidocaine 1 percent infiltration
›Avoid intraarticular steroid in acute fracture setting
Antibiotics and Tetanus for Open Injury
›Open fracture prophylaxis
›Cefazolin
›2 g IV every 8 hours
›Increase to 3 g IV every 8 hours if very high body mass
›Start as soon as possible after recognition
›Severe cephalosporin allergy
›Clindamycin 900 mg IV every 8 hours
›MRSA risk context consideration
›Gross contamination or farm injury
›Add gentamicin 5 mg per kg IV once
›Renal dosing adjustment required
›Tetanus prophylaxis
›If unknown or fewer than 3 prior doses then tetanus immunoglobulin plus vaccine
›If 3 or more prior doses then booster based on wound type and time since last dose
Operative Pathway Overview
›Operative indications overview
›Disrupted extensor mechanism
›Inability to perform straight leg raise not explained by pain alone
›Displaced fracture and articular incongruity
›Step off and gap exceeding local orthopedic thresholds
›Open fracture
›Irrigation and debridement and fixation planning
›Large osteochondral fragment or loose body
›Mechanical symptoms or joint block
›Fixation concepts
›Tension band constructs for transverse fractures
›Converts tensile forces to compressive forces in flexion
›Screws and cerclage options for comminution
›Fragment specific fixation
›Partial patellectomy for nonreconstructible inferior pole
›Extensor mechanism restoration priority
Thrombosis and Immobilization Considerations
›VTE risk considerations
›Lower limb immobilization increases VTE risk
›Individual risk stratification for prophylaxis decision
›High risk features
›Prior VTE
›Active cancer
›Major trauma or prolonged non weight bearing
›Prophylaxis planning
›Coordinate with orthopedics or primary care for outpatient plan when indicated