What treatment and management plan should be recommended for a patient with prepatellar soft tissue swelling and intact right knee and patella after a fall?

Management of Prepatellar Soft Tissue Swelling After Fall

Immediate Treatment Plan

Apply cold therapy (ice and water surrounded by a damp cloth) for 20-30 minutes without direct skin contact, place the knee in a brace for functional support, limit weight-bearing activities that cause pain, and arrange follow-up within 3-5 days for reassessment when swelling has decreased. 1, 2

Initial Management (First 48 Hours)

Cold Application Protocol

• Apply ice and water mixture surrounded by a damp cloth to the prepatellar area for 20-30 minutes per application 1
• Repeat cold applications 3-4 times daily for acute pain and swelling relief 1
• Never place ice directly on skin to prevent cold injury 1
• Cold therapy provides acute pain relief and reduces swelling, though it does not improve long-term functional outcomes 1

Functional Support with Knee Brace

• Apply a knee brace immediately for protection and comfort 2
• The brace allows protected weight-bearing while restricting excessive motion during the healing phase 2
• Avoid prolonged rigid immobilization beyond what is needed for initial pain control, as this delays recovery without improving outcomes 2
• Continue brace use for 4-6 weeks as functional support 2

Activity Modification

• Avoid all activities that cause pain to prevent further damage and promote healing 1
• Reduce repetitive loading of the affected knee 1
• Weight-bearing should be as tolerated, avoiding only movements that reproduce pain 2

Follow-Up Timing and Rationale

Critical 3-5 Day Reassessment

• Schedule follow-up examination in 3-5 days when swelling has subsided 2
• This delayed examination is essential because initial assessment cannot accurately distinguish between simple soft tissue injury and more serious pathology 2
• Clinical assessment of tissue damage is optimized when swelling has decreased, allowing better palpation and range of motion testing 2

What to Monitor at Follow-Up

• Ability to perform straight leg raise (inability suggests more serious injury) 3
• Presence of knee effusion (suggests intra-articular pathology) 3
• Ability to bear weight (inability suggests significant injury requiring imaging) 2
• Range of motion limitations 1
• Persistent or worsening pain, particularly at rest or night 1

Pain Management

First-Line Analgesics

• NSAIDs (ibuprofen, naproxen, or celecoxib) are recommended for short-term pain relief (less than 14 days) 1, 2
• NSAIDs reduce pain and swelling but do not alter long-term outcomes 1
• Acetaminophen is equally effective if NSAIDs are contraindicated 2
• Avoid opioids as they cause significantly more side effects without superior pain relief 2

Red Flags Requiring Urgent Reassessment

Signs of Serious Injury

• Inability to perform straight leg raise (suggests extensor mechanism disruption or patellar fracture) 3
• Significant knee effusion (suggests intra-articular injury) 3
• Inability to bear weight at all 3
• Severe or worsening pain at rest or night (suggests infection or fracture) 1
• Visible deformity or patellar displacement 3

When to Consider Imaging

• Point tenderness directly over the patella 2
• Inability to bear weight for four steps 2
• Prepatellar swelling greater than 12mm on clinical measurement 3
• Maximum fragment displacement or visible bony irregularity 3
• Failure to improve with conservative management after 3-5 days 2

Common Pitfalls to Avoid

• Do not immobilize the knee beyond initial pain control (3-5 days maximum), as prolonged immobilization leads to decreased range of motion, chronic pain, and joint stiffness without demonstrated benefits 2
• Do not skip the 3-5 day follow-up examination, as initial assessment cannot distinguish partial injuries from complete disruptions 2
• Do not apply heat to acute injuries, as this is not recommended and may worsen swelling 2
• Do not delay imaging if red flags are present, particularly inability to straight leg raise or significant effusion 3

Patient Instructions to Provide

For the Next 48 Hours

• Apply ice and water (in a damp cloth) for 20 minutes, 3-4 times daily 1
• Wear the knee brace continuously except when applying ice 2
• Avoid stairs, squatting, kneeling, and activities causing pain 1
• Take NSAIDs as directed for pain control 1, 2
• Elevate the leg when sitting or lying down 1

Return Precautions

• Return immediately if unable to straighten the leg or perform straight leg raise 3
• Return if swelling worsens significantly or becomes hot and red 4
• Return if pain becomes severe at rest or night 1
• Return if unable to bear any weight on the leg 3

Expected Follow-Up in 3-5 Days

• Reassessment when swelling has decreased allows accurate diagnosis 2
• Decision about need for imaging will be made at that visit 2
• Rehabilitation exercises will be initiated if appropriate 2