Immediate Management of Acute Patellar Dislocation with Severe Pain
This 15-year-old requires immediate pain control with NSAIDs or opioids if needed, followed by radiographic imaging (AP, lateral, and patellofemoral views) to rule out osteochondral fractures, then functional bracing for 4-6 weeks with early physical therapy. 1
Acute Pain Management
The extreme pain and vomiting indicate significant soft tissue injury and possible osteochondral damage that requires aggressive symptom control:
- Administer NSAIDs for short-term pain relief, as they are effective for acute tendon and ligament injuries, though they don't alter long-term outcomes 2
- Consider opioid analgesia if NSAIDs are insufficient, given the severity of symptoms (pain causing vomiting suggests inadequate pain control)
- Apply ice therapy immediately: repeated applications of melting ice water through a wet towel for 10-minute periods provide acute pain relief 2
- Avoid rigid immobilization beyond 10 days maximum if used for severe pain or edema, then transition to functional support 1
Mandatory Imaging Workup
Obtain radiographs immediately to assess for fractures and confirm reduction:
- Minimum two views required: anteroposterior and lateral radiographs of the affected knee 2, 1
- Add patellofemoral (axial) view to evaluate for patellar fractures and degree of subluxation or dislocation 1
- Follow with MRI after initial radiographs to characterize bone and soft-tissue injuries, particularly osteochondral fractures, bone marrow contusions, and medial patellofemoral ligament (MPFL) injury 2, 1
The MRI is critical because osteochondral fractures occur frequently with patellar dislocations and would change management to surgical intervention 1, 3.
Treatment Algorithm Based on Imaging
If No Osteochondral Fracture (Most Likely Scenario)
Proceed with nonoperative management as first-line treatment:
- Functional bracing with ankle-style functional brace for 4-6 weeks is strongly preferred over rigid immobilization 1
- Braces show the greatest treatment effects compared to other types of functional support 1
- Begin neuromuscular exercises and stretching as these are the most commonly recommended physiotherapy methodologies 4
- Approximately 60-70% of patients respond well to nonoperative treatment 1
If Osteochondral Fracture Present
Surgery is indicated primarily for osteochondral fractures or significant concomitant injuries identified on imaging 1:
- MPFL reconstruction is the primary procedure currently selected by most surgeons as first-line treatment, as the MPFL ruptures in almost all patellar dislocations 3
- Anatomic procedures (especially MPFL reconstruction) are more effective in preventing recurrent dislocation compared with non-anatomic techniques 3
Critical Pitfalls to Avoid
Do not immobilize rigidly for more than 10 days if used at all, as this increases stiffness and impairs mobility 1. The severe pain in this case may tempt providers to immobilize, but functional bracing is superior.
Do not dismiss the vomiting as purely pain-related without imaging—it could indicate a displaced osteochondral fragment or other significant injury requiring surgical intervention 1.
Do not assume successful reduction means no fracture—osteochondral fractures frequently accompany patellar dislocations and may not be clinically apparent 3, 5.
Special Considerations for Adolescents
- Younger age at first dislocation is associated with increased severity of predisposing factors and higher risk of recurrence 3
- Skeletal immaturity precludes certain osseous procedures to avoid premature physis closure and limb deformity 3
- If multiple instability factors are present on MRI, acute MPFL reconstruction may be considered even for first-time dislocation in this age group 3