What are the post-discharge instructions for a child with a possible occult fracture, presenting with knee swelling, who is being sent home with a knee brace and on crutches (crutch-assisted walking device)?

Post-Discharge Instructions for Child with Knee Swelling and Possible Occult Fracture

Your child should remain non-weight-bearing or partial weight-bearing on crutches with the knee brace in place for the next 1-2 weeks, with mandatory follow-up for repeat imaging if pain persists, as occult fractures may only become visible on follow-up radiographs and can cause severe complications if missed.

Immediate Home Care (First 48-72 Hours)

Weight-Bearing Status

• Use crutches for all ambulation to maintain partial or non-weight-bearing status on the affected leg 1
• Instruct your child to bear weight only as tolerated by pain—if it hurts, they should not put weight on it 2
• Consider using bilateral crutches or a walker for better stability and to reduce pressure on the affected limb 1
• The crutches help reduce: (1) pressure on the injured knee, (2) risk of falls, (3) time to healing, and (4) risk of injury to the other leg from overcompensation 1

Knee Brace Management

• Keep the knee brace on at all times except for bathing and skin checks 3
• Check the skin under the brace twice daily for any redness, irritation, or breakdown 1
• Ensure the brace fits properly—not too tight (which can cause skin injury) or too loose (which provides inadequate support) 1

Pain and Swelling Control

• Elevate the leg above heart level whenever sitting or lying down for the first 48-72 hours 3
• Apply ice for 15-20 minutes every 2-3 hours while awake for the first 2-3 days 3
• Give pain medication as prescribed or recommended (typically acetaminophen or ibuprofen) 3

Activity Restrictions

What Your Child Should NOT Do

• No running, jumping, sports, or physical education class until cleared by the follow-up provider 3
• No climbing stairs without assistance 1
• No weight-bearing activities even if pain improves—occult fractures can worsen with premature activity 2
• Avoid removing the brace except as instructed above 1

What Your Child CAN Do

• Gentle range-of-motion exercises if instructed (typically ankle pumps and gentle knee bending within pain limits) 4
• Upper body activities while seated 3
• School attendance with accommodations (elevator access, extra time between classes, permission to keep leg elevated) 1

Critical Warning Signs—Seek Immediate Care If:

• Increasing pain despite medication (may indicate worsening fracture or compartment syndrome) 2
• Numbness, tingling, or coldness in the foot or toes 3
• Inability to move the toes 3
• Skin breakdown, blistering, or open wounds under the brace 1
• Fever above 100.4°F (38°C) or signs of infection (increased warmth, redness spreading beyond the knee) 3
• Severe swelling that causes the brace to feel too tight 1

Follow-Up Care—MANDATORY

Timing of Follow-Up

• Schedule follow-up within 5-7 days or as specifically instructed 3
• If pain persists beyond 1-2 weeks, repeat imaging (X-rays or possibly MRI) is necessary to detect occult fractures that were not visible on initial radiographs 1, 2
• Approximately 10% of fractures are only visible on follow-up radiographs, so normal initial X-rays do NOT rule out fracture 3

What to Expect at Follow-Up

• Repeat physical examination to assess swelling, tenderness, and range of motion 3
• Possible repeat X-rays to look for fracture line that may now be visible due to early bone healing response 1
• If X-rays remain negative but pain persists, MRI may be recommended as it is the most sensitive test for occult fractures and can detect bone marrow edema patterns that indicate injury 1, 2
• CT scan may be considered if MRI is not available, as it can detect subtle fractures missed on plain radiographs 1

Special Considerations

Why This Conservative Approach Matters

• Occult fractures cannot be seen on initial X-rays but cause bone marrow edema and can progress to complete fractures if not protected 2, 5
• The clinical prognosis is generally good with appropriate immobilization and protected weight-bearing 2
• Missing an occult fracture combined with ligamentous injury can lead to severe complications and prolonged disability 2, 6

Duration of Restrictions

• Expect immobilization and activity restrictions for at least 2-4 weeks, possibly longer depending on follow-up findings 1, 3
• Weight-bearing will be advanced gradually based on pain improvement and follow-up imaging results 1, 2
• Full return to sports typically requires 6-12 weeks and clearance from the treating physician 3

Psychological and Social Support

• Long-term mobility restrictions can affect your child's psychological health and social well-being 1
• Arrange for school accommodations and maintain social connections through non-physical activities 1
• Monitor for signs of frustration or depression related to activity limitations 1

Common Pitfalls to Avoid

• Do not assume normal initial X-rays mean no fracture—occult fractures are by definition not visible initially 3, 2
• Do not allow weight-bearing based solely on pain improvement—structural healing takes time regardless of symptom improvement 2
• Do not skip follow-up appointments—late displacement or complications can occur and must be detected early 3
• Do not ignore persistent pain beyond 1-2 weeks—this warrants advanced imaging (MRI or CT) to rule out occult fracture 1, 2