Immediate life-saving interventions
›Immediate stabilization
›Vascular compromise pathway
›Immediate reduction attempt if dislocation suspected and pulses absent
›Post-reduction pulse reassessment
›If persistent ischemia then emergent orthopedics and vascular consultation
›Analgesia for severe pain while preparing reduction
›Non-opioid analgesia options
›Acetaminophen PO 1000 mg once
›Ibuprofen PO 400 mg once
›Opioid titration options
›Fentanyl IV 0.5 to 1 mcg per kg
›Repeat fentanyl IV 0.5 mcg per kg every 5 minutes to effect
›Threatened skin management
›Immediate reduction when skin tenting present
›Avoid repeated forceful attempts
Immobilization and Splinting
›Post-reduction immobilization options
›Knee immobilizer in extension
›Patellar stabilizing brace when available
›Hinged knee brace locked in extension initially when prescribed by specialist
›Immobilization principles
›Extension position reduces lateral translation risk acutely
›Neurovascular reassessment after brace placement
›Avoid circumferential casting in acute swelling phase
›Mobility support
›Crutches
›Weight bearing as tolerated if stable and pain controlled
›Non weight bearing if severe pain or instability
›Indications for reduction
›Persistent lateral patellar displacement
›Severe pain with visible deformity
›Threatened skin
›Contraindications or caution triggers
›Suspected knee dislocation rather than patellar dislocation
›Open injury
›Gross instability suggesting major ligament injury
›Analgesia and anesthesia options
›Minimal sedation pathway when cooperative
›IV opioid only
›Fentanyl IV 0.5 to 1 mcg per kg
›Re-dose as needed
›Regional anesthesia options
›Adductor canal block or femoral nerve block
›Ropivacaine 0.5% 15 to 20 mL
›Maximum ropivacaine 3 mg per kg
›Alternative local anesthetic
›Bupivacaine 0.25% 15 to 20 mL
›Maximum bupivacaine 2.5 mg per kg
›Procedural sedation pathway when needed
›Monitoring and airway readiness
›Cardiac monitor
›Continuous pulse oximetry
›Capnography when available (ACEP Level B)
›Suction available
›Bag valve mask available
›Ketamine option
›Ketamine IV 1 to 2 mg per kg
›Additional ketamine IV 0.5 mg per kg as needed
›Propofol option
›Propofol IV 0.5 to 1 mg per kg
›Additional propofol IV 0.25 to 0.5 mg per kg as needed
›Etomidate option
›Etomidate IV 0.1 to 0.2 mg per kg
›Additional etomidate IV 0.05 mg per kg as needed
›Technique principles
›Hip flexion to relax quadriceps
›Slow knee extension while applying medial pressure to patella
›Gentle sustained force
›Stop if severe resistance or concern for alternate injury
›Post-reduction requirements
›Immediate neurovascular re-check
›Active extension check
›Post-reduction radiographs
›Brace placement in extension
›Failed reduction pathway
›If irreducible then urgent orthopedics
›If worsening neurovascular status then emergent escalation
›If mechanical block then concern for loose body and urgent imaging