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How is a knee dislocation handled by doctors?

Q: Our daughter dislocated her knee cap for the first time during slow pitch. She wants to get right back in the game. The orthopedic surgeon is saying six weeks of a brace or splint first. How is this kind of injury handled by other doctors?

A: Despite how often this type of injury occurs in young athletes, there isn't a great deal of evidence to direct treatment. Surgeons use an algorithm (step-by-step approach) to the management of first-time patellar (knee cap) dislocations. This algorithm has been published in sports and orthopedic journals. It is based on current evidence and has been revised as new data is available.

The algorithm directs the physician to conduct a thorough history and physical examination. The history includes questions about how, when, and why the injury happened. It's important to find out if the patient ever had a similar injury in the past (for either knee). A previous history of knee dislocation is a red flag for recurrent (repeated) patellar dislocations.

Clinical tests performed by the physician must confirm that a patellar dislocation occurred. Just as important, the examiner checks for any injuries or damage to other areas of the knee (e.g., ligaments, cartilage, connective tissue, bone). X-rays and MRIs help identify areas of damage to the joint surface. MRIs are especially helpful in looking for any fragments of bone or cartilage in the joint.

Conservative care is the main approach for this problem. Surgery is only considered when there is a large fragment displaced. And that piece of bone or cartilage must be big enough to have at least one or two pins put through it to reattach it to the main bone.

Otherwise, all evidence points to the conservative approach recommended by your surgeon. Reducing the time of immobilization to less than the six weeks needed for full healing and recovery is risky.

Those patients who stop wearing a brace after only three weeks are at a much higher risk of a repeat dislocation. Recurrent damage makes it harder for the knee to heal and regain stability. The evidence suggests that every effort should be made to convince your daughter to follow the surgeon's advice at the front end.

It's disappointing to be out of the game right out of the gate. But in the big picture, this conservative approach may help ensure many more years of injury-free sports participation.

Reference: Neel P. Jain, MD, et al. A Treatment Algorithm for Primary Patellar Dislocations. In Sports Health. March/April 2011. Vol. 3. No. 2. Pp. 170-174.

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