Patellar Laceration Management in the Emergency Department
Patellar lacerations require thorough wound irrigation, careful debridement of contaminated tissue, and layered closure with particular attention to the prepatellar bursa, followed by loop drainage placement to prevent fluid accumulation.
Initial Wound Assessment and Preparation
Wound Cleaning Protocol
- Remove superficial debris carefully, avoiding aggressive debridement that unnecessarily enlarges the wound 1
- Irrigate the wound copiously under pressure to remove all contamination 2
- Prepare the wound site with betadine or chlorhexidine antiseptic solution 1
- Explore the wound completely to assess depth and involvement of underlying structures 3
Radiographic Evaluation
- Obtain radiographs if there is concern for patellar fracture or retained foreign body 2
- This is critical as patellar fractures may be present and require different management 4
Anesthesia Administration
Topical Options
- Apply LET solution (lidocaine-epinephrine-tetracaine) for 10-20 minutes until wound edges blanch 1
- Contraindicated if gross contamination is present 1
Injectable Anesthesia
- Use subdermal application of local anesthesia through exposed wound margins 3
- Buffer lidocaine with bicarbonate, warm before injection, and inject slowly with small-gauge needle to minimize pain 1
Surgical Repair Technique
Bursa Management
- Dissect the boundary layer between the prepatellar bursa and subcutaneous fat 3
- Perform gentle, risk-balanced partial resection of traumatic lacerated prepatellar bursa tissue 3
- Debride bruised and contaminated bursa tissue while preserving viable tissue 3
- This step is critical to prevent chronic bursitis and infection 3
Layered Closure Approach
- The skin's greatest strength lies in the dermal layer, requiring accurate approximation of the entire dermal depth 2
- Use continuous non-locking subcuticular technique to distribute tension evenly 1
- Avoid transcutaneous interrupted sutures as they damage nerve endings and increase pain 1
- Fat and muscle do not support sutures effectively 2
Drainage Placement
- Insert loop drainage before wound closure 3
- Remove drainage on postoperative day 2 during first wound inspection 3
- This prevents seroma and hematoma formation in the prepatellar space 3
Final Closure
- Perform single-layer wound closure after drainage placement 3
- Apply crepe bandage until first wound inspection 3
Antibiotic Management
Prophylactic antibiotics are NOT routinely indicated for clean patellar lacerations 1
Indications for Antibiotics
- Heavy contamination of the wound 3
- Immunocompromised or polymorbid patients 3
- Signs of established infection 1
Antibiotic Selection
Post-Repair Management
Immediate Care
- Apply crepe bandage until first wound inspection 3
- Wound inspection on postoperative day 2 with removal of loop drainage 3
Functional Recovery
- Pain-adapted functional treatment after drainage removal 3
- Antithrombotic therapy until full weight-bearing is achieved 3
- Remove sutures on postoperative day 14 3
Tetanus Prophylaxis
- Administer 0.5 mL intramuscularly if status is outdated or unknown 1
Contraindications to Primary Closure
- Large, non-closable skin defect or deep abrasion 3
- Preexisting local infection 3
- Additional fracture of the patella requiring orthopedic management 3
- Limited patient cooperation (e.g., alcohol addiction or dementia) 3
Common Pitfalls to Avoid
- Never close infected wounds primarily - these require delayed closure after infection resolution 1
- Avoid aggressive debridement that enlarges the wound and impairs closure 1
- Do not neglect the prepatellar bursa - failure to address it leads to complications 3
- Avoid using antimicrobial ointments routinely as they have not been shown effective for infection prevention 5
- Do not skip drainage placement in prepatellar bursa injuries - this prevents fluid accumulation 3