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Orthopedics & Traumatology

Patella Fracture, Right, Transverse, Closed, Initial Encounter

ICD-10 Code
S82.021A

Standardized diagnosis for Patella Fracture, Right, Transverse, Closed, Initial Encounter.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with acute right knee pain following a direct trauma/fall. Reports inability to bear weight, significant swelling, and localized tenderness over the patella. No neurovascular deficits noted in the distal extremity. Mechanism of injury consistent with direct impact to the anterior knee.

Clinical Examination Findings

Right knee inspection reveals significant anterior swelling, ecchymosis, and a palpable gap or step-off at the patellar mid-substance. Tenderness to palpation is maximal over the patella. Active straight leg raise is absent/impaired. Range of motion is severely limited by pain. Distal pulses (DP/PT) are 2+ and symmetric; capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes.

Treatment Protocol

Immobilization of the right knee in full extension using a knee immobilizer. Ice application for 20 minutes every 2 hours. Elevation of the right lower extremity above heart level. Analgesia provided. Orthopedic consultation requested for surgical fixation evaluation. Non-weight bearing status strictly enforced.

Detailed clinical guide coming soon.