What is the treatment for a 12-year-old girl with a reduced patellar dislocation?

Management of Patellar Dislocation in a 12-Year-Old Girl

For a 12-year-old girl with a reduced patellar dislocation, the recommended initial treatment is conservative management with a neoprene nonhinged knee brace for 4 weeks, followed by physical therapy focusing on quadriceps strengthening.

Initial Assessment and Management

Immediate Care

• Confirm that the patella is properly reduced
• Assess for osteochondral fractures or other associated injuries
• Evaluate for anatomical predispositions to patellar instability

First-Line Treatment

1. Bracing:

   • Use a neoprene nonhinged knee brace rather than a motion-restricting brace
   • Evidence shows that motion-restricting braces do not significantly reduce redislocation rates (34.4% vs 37.5%) compared to nonhinged braces 1
   • Motion-restricting braces are associated with:
     • Greater quadriceps atrophy
     • Reduced knee range of motion
     • Worse functional outcomes in the first 6 months 1

2. Duration of Bracing:

   • Continuous brace use for 4 weeks 1
   • Gradually discontinue as quadriceps strength improves

Rehabilitation Protocol

Early Phase (0-4 weeks)

• Protected weight-bearing as tolerated
• Gentle range of motion exercises
• Isometric quadriceps exercises
• Ice and elevation for swelling control

Intermediate Phase (4-8 weeks)

• Progressive quadriceps strengthening
• Hamstring stretching
• Proprioceptive training
• Core strengthening

Advanced Phase (8-12 weeks)

• Sport-specific exercises
• Functional training
• Return to activity when:
  • Full range of motion achieved
  • Quadriceps strength at least 80% of contralateral side
  • No apprehension with lateral patellar stress

Monitoring and Follow-up

• Clinical reassessment at 4 weeks, 3 months, and 6 months
• Evaluate for:
  • Recurrent instability
  • Quadriceps strength
  • Range of motion
  • Functional limitations

Indications for Surgical Referral

Refer to a pediatric orthopedic surgeon if:

• Osteochondral fracture is present
• Recurrent dislocation occurs (approximately 35% of patients will have recurrence) 2
• Persistent instability despite adequate conservative treatment
• Significant anatomical predisposition to recurrent instability

Surgical Options (if conservative management fails)

For recurrent dislocations, surgical options include:

• Medial patellofemoral ligament (MPFL) reconstruction
• Tibial tubercle osteotomy (in skeletally mature patients)
• Lateral retinacular release

Important Considerations

1. Age-Specific Concerns:

   • Skeletal immaturity must be considered when planning treatment
   • Avoid procedures that might affect growth plates in this 12-year-old patient

2. Common Pitfalls to Avoid:

   • Prolonged immobilization leading to quadriceps atrophy
   • Overlooking anatomical predispositions to recurrent instability
   • Delaying appropriate rehabilitation
   • Returning to sports too early before adequate strength is regained

3. Prognosis:

   • Good outcomes are expected with appropriate conservative management for first-time dislocations
   • Approximately 65% of patients will not experience recurrence 2
   • Early identification and treatment of predisposing factors may reduce recurrence risk

The evidence strongly supports conservative management for first-time patellar dislocations in skeletally immature patients, with surgical intervention reserved for recurrent instability or significant concomitant injuries 2, 3.