Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Traumatic Injuries Allan J. Ryan To cite this article: Allan J. Ryan (1976) Traumatic Injuries, Postgraduate Medicine, 59:6, 195-197, DOI: 10.1080/00325481.1976.11714401 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714401
Published online: 07 Jul 2016.
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Citing articles: 2 View citing articles
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Date: 09 August 2017, At: 14:35
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family practice notebook • The seriousness of a bruise may not be apparent from the appearance of the overlying skin. A superficial bruise may yield an immediate} y spectacular ecchymosis but will heal under any treatment or none at ali. A deep bruise will usually also heal spontaneously, but without treatment the consequences may be unpleasant. Prompt and perceptive treatment minimizes the immediate effects of a deep bruise and avoids entirely any lasting effects. A severe bruising force may crush and tear subcutaneous fat, fascia, muscle, blood vessels, nerves, and periosteum, or these tissues may be gradually compressed as local swelling occurs. Early swelling is caused chiefly by pooling of blood released from torn veins and small arterioles. The swelling is gradually increased by oozing from capillaries and lymphatics and by ekudation offluid from the intracellular space, a process stimulated by histamine liberated from damaged cells. A subcutaneous ecchymosis may not appear for severa} days if the major injury is to deep-seated muscle. When an ecchymosis does become visible, it may be a slight distance from the site of injury, at a place where blood flow is blocked by intact fascia or where the blood reaches a more dependent point. To prevent swelling and the resultant pain and disruption of soft tissues, control of bleeding is necessary. The acronym ICE serves as a reminder that this is best done by the local application of ice or cold, by compression, and by elevation of the affected part (above the level of the heart, if possible). There is no rule of thumb for the duration of this therapy, but in general it should be maintained for at least 24 hours (and probably considerably longer than the patient feels is necessary). lee, enclosed in a plastic or rubber bag covered with a light towel, has no superior in the cold treatment of injury. Light chemical packs that become cold when activated are a convenience if refrigeration is unavailable, but they stay cold for a relatively brief period and, if the bag breaks, a chemical burn may result. A heavier, reusable chemical pack stays cold longer but, like ice, requires refrigeration before it can be used. Having ice available in the office is advantageous not only for early local treatment but for later use in massage. Compression is most readily applied by using elasticized
traumatic • • • InJuries OFFICE TREATMENT OF DEEP BRUISES Allan J. Ryan, MD
Minneapolis
Local application of cold, compression, and elevation of the injured part are the mainstays of emergency care of a suspected deep bruise. Lack of treatment may have unpleasant consequences, such as muscle shortening.
One of a series of articles coordinated by Dr. Ryan.
Vot. 59 • No. 6 • June 1976 • POSTGRADUATE MEDICINE
195
Downloaded by [Australian Catholic University] at 14:35 09 August 2017
Compression diminishes the pain of a deep bruise and prevents dependent swelling when the patient is active.
cotton bandage. As an additional aid to control of swelling, the bandage may be soaked in ice water before application or an ice bag may be held in position by the bandage. If elastic bandage is applied to an extremity, care must be taken to monitor the pulse distal to the bandage, to insure that arterial circulation is not being eut off. Compression should be maintained even after cold treatment is discontinued, as it diminishes pain from the injury and prevents dependent swelling when the patient is active. The bandage may be removed at night to prevent distal swelling due to slowing of the circulation during sleep. If convenient, and if the ti me sin ce bru ising is short, the physician should have the patient lie down for about an hour with the injured part elevated. The patient should be strongly encouraged to elevate the bruised part again immediately on returning home and to continue to do so for at least 24 hours. Weight bearing by an injured leg should not be allowed until it does not cause pain, and the patient should be provided with crutches or, in the case of an arm bruise, with sling support, before leaving the office. Medical opinion is divided on whether to attempt aspiration of a localized hematoma in a bruised area. In my experience, little is gained by such an attempt and further harm may be done if a vein is entered or transfixed during the procedure. A hematoma is ordinarily diffused in a muscle bruise and the blood clots quickly. Aspiration may be of value later when serum has separated from cells and fibrin and the clot has partially liquefied. I have not found that injecting hyaluronidase into bruised areas hastens absorption of blood and tissue fluid appreciably. Sorne physicians advocate infiltrating corticosteroid loc ally, but well-documented proof of effectiveness is lacking. Both procedures run the risk of precipitating further bleeding, and the extent to which corticosteroid injection might retard healing has not been determined. The oral administration of proteolytic enzymes has been advocated, but as yet no firm conclusions can be drawn.
196
In managing deep muscle bruises, the important priority after bleeding has been controlled is to maintain muscle length and strength. This may be accomplished by having the patient contract the injured muscle isometrically and then perform active rangeof-motion exercises. Attempts to increase the range passive! y should be avoided, since they may invoke muscle spasm and cause further damage to muscle substance. Exercises should be carried out every two to three hours during the day, beginning with five repetitions of each and progressing gradually to 20. Pain can be relieved considerably by the use of ice massage loc ally be fore exercise is begun. When the injured extremity can go through a normal range of motion without pain, a program of exercises against progressively increasing resistance may be carried out until full muscle strength is restored. At this time use of the compression bandage is discontinued and the patient can gradually resume normal activity. The full range of joint motion should be maintained by continuing regular exercise for sorne weeks to prevent muscle shortening due to the graduai contraction of fibrous scar tissue at the injury site. Residual subcutaneous masses from organized hematomas are best left al one if they are not very large or pain fui. Over a period of months they will shrink and sorne will disappear. Massage over the injured part should be avoided, since it appears to exaggerate any tendency to myositis ossificans. This condition apparently occurs when injury stimulates mesenchymal cells in the muscle fascia to function as osteoblasts and to lay down real bone within the muscle. Soft-tissue x-ray examination will detect the presence of myositis ossificans as early as three weeks after injury. The inflammation must be allowed to run its course until stability is achieved, ie, no further bone formation is detected by x -ray. This may take from six weeks to six months. Attempts to excise the area before the process stabilizes may result in recurrence. Rehabilitation should proceed in
POSTGRADUATE MEDICINE
o
June 1976
o
Vol. 59
o
No. 6
problems solutions spite of the presence of inflammation, although the rigidity it gives to the muscle may make exercising more difficult.
Downloaded by [Australian Catholic University] at 14:35 09 August 2017
Summary
The first step in treating severe bruises is to control subcutaneous bleeding and thereby prevent the swelling that causes pain and disruption of soft tissues. Control is best accomplished by applying ice packs and compression to the site of injury and, if an extremity is involved, by elevating the limb above the level of the heart. This therapy should be maintained for at least 24 hours. A second priority is to maintain muscle length and strength. This can be done by instituting a program of active range-of-motion exercises followed by resistive exercises until full muscle strength is restored. • Address reprint requests to Editorial Department, POSTGRADUATE MEDICINE, 4530 W 77th St, Minneapolis, MN 55435.
Blbllography Abraham WM: Heat vs. cold therapy for the treatment of muscle injuries. Natl Athletic Trainers Assoc 9:177-179, 1974 Brewer BJ: Athletic injuries: Musculo-tendinous unit. In DePalma AF (Editor): Clinicat Orthopaedics, No. 23. Philadelphia, JB Lippincott, 1962, pp 30-27 Ellis M, Frank HG: Myositis ossificans traumatica: With special reference to the quadriceps femoris muscle. J Trauma 6:724-738, 1966 Glick JM: The use of therapeutic agents for musculo-skeletal injuries in athletics. In Committee on Medical Aspects of Sports (Editors): Medical Aspects of Sports. Chicago, American Medical Association, 1974, pp 29-31 Millar AP, Salmon J: Muscle tears. Aust Sports Med 2:35-42, 1967 Moore RJ Jr, Nicolette RL, Behnke RS: The therapeutic use of co1d (cryotherapy) in the care of athletic injuries. Natl Athletic Trainers Assoc 2:6-13, 1967 Peppard A: Myotonic muscle distress: A rationale for therapy. Natl Athletic Trainers Assoc 8:166-169, 1973 Rask MR, Lattig GJ: Traurnatic fibrosis of the rectus femoris muscle: Report of five cases and treatment. JAMA 221:268-269, 1972 Ryan AJ: Quadriceps strain, rupture and charlie horse. Med Sei Sports 1:106-111, 1969 Ryan AJ, Allman FL Jr (Editors): Sports Medicine. New York, Academie Press, 1974, chs 12, 13 Salmon J: Physiotherapy in hamstring injuries. Aust Sports Med 2:19-24, 1968 Smith ET: Myositis ossificans of the humerus (Biocker's disease). Tex Med 56:678-680, . 960
Vol. 511 • No. 8 • June 1978 • POSTGRADUATE IEDICifE
MayWe Help Vou? When you want consultation about current methods of diagnosis or treatment for a problem case, send us your query along with pertinent data. We will submit your question to our consultants and promptly forward the reply to you. Selected problems are published anonymously each month. Address queries to:
Problems/Solutions POSTGRADUATE MEDICINE 4530 W 77th St Minneapolis, MN 55435
197
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Traumatic Injuries Allan J. Ryan To cite this article: Allan J. Ryan (1976) Traumatic Injuries, Postgraduate Medicine, 59:6, 195-197, DOI: 10.1080/00325481.1976.11714401 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714401
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 09 August 2017, At: 14:35
Downloaded by [Australian Catholic University] at 14:35 09 August 2017
family practice notebook • The seriousness of a bruise may not be apparent from the appearance of the overlying skin. A superficial bruise may yield an immediate} y spectacular ecchymosis but will heal under any treatment or none at ali. A deep bruise will usually also heal spontaneously, but without treatment the consequences may be unpleasant. Prompt and perceptive treatment minimizes the immediate effects of a deep bruise and avoids entirely any lasting effects. A severe bruising force may crush and tear subcutaneous fat, fascia, muscle, blood vessels, nerves, and periosteum, or these tissues may be gradually compressed as local swelling occurs. Early swelling is caused chiefly by pooling of blood released from torn veins and small arterioles. The swelling is gradually increased by oozing from capillaries and lymphatics and by ekudation offluid from the intracellular space, a process stimulated by histamine liberated from damaged cells. A subcutaneous ecchymosis may not appear for severa} days if the major injury is to deep-seated muscle. When an ecchymosis does become visible, it may be a slight distance from the site of injury, at a place where blood flow is blocked by intact fascia or where the blood reaches a more dependent point. To prevent swelling and the resultant pain and disruption of soft tissues, control of bleeding is necessary. The acronym ICE serves as a reminder that this is best done by the local application of ice or cold, by compression, and by elevation of the affected part (above the level of the heart, if possible). There is no rule of thumb for the duration of this therapy, but in general it should be maintained for at least 24 hours (and probably considerably longer than the patient feels is necessary). lee, enclosed in a plastic or rubber bag covered with a light towel, has no superior in the cold treatment of injury. Light chemical packs that become cold when activated are a convenience if refrigeration is unavailable, but they stay cold for a relatively brief period and, if the bag breaks, a chemical burn may result. A heavier, reusable chemical pack stays cold longer but, like ice, requires refrigeration before it can be used. Having ice available in the office is advantageous not only for early local treatment but for later use in massage. Compression is most readily applied by using elasticized
traumatic • • • InJuries OFFICE TREATMENT OF DEEP BRUISES Allan J. Ryan, MD
Minneapolis
Local application of cold, compression, and elevation of the injured part are the mainstays of emergency care of a suspected deep bruise. Lack of treatment may have unpleasant consequences, such as muscle shortening.
One of a series of articles coordinated by Dr. Ryan.
Vot. 59 • No. 6 • June 1976 • POSTGRADUATE MEDICINE
195
Downloaded by [Australian Catholic University] at 14:35 09 August 2017
Compression diminishes the pain of a deep bruise and prevents dependent swelling when the patient is active.
cotton bandage. As an additional aid to control of swelling, the bandage may be soaked in ice water before application or an ice bag may be held in position by the bandage. If elastic bandage is applied to an extremity, care must be taken to monitor the pulse distal to the bandage, to insure that arterial circulation is not being eut off. Compression should be maintained even after cold treatment is discontinued, as it diminishes pain from the injury and prevents dependent swelling when the patient is active. The bandage may be removed at night to prevent distal swelling due to slowing of the circulation during sleep. If convenient, and if the ti me sin ce bru ising is short, the physician should have the patient lie down for about an hour with the injured part elevated. The patient should be strongly encouraged to elevate the bruised part again immediately on returning home and to continue to do so for at least 24 hours. Weight bearing by an injured leg should not be allowed until it does not cause pain, and the patient should be provided with crutches or, in the case of an arm bruise, with sling support, before leaving the office. Medical opinion is divided on whether to attempt aspiration of a localized hematoma in a bruised area. In my experience, little is gained by such an attempt and further harm may be done if a vein is entered or transfixed during the procedure. A hematoma is ordinarily diffused in a muscle bruise and the blood clots quickly. Aspiration may be of value later when serum has separated from cells and fibrin and the clot has partially liquefied. I have not found that injecting hyaluronidase into bruised areas hastens absorption of blood and tissue fluid appreciably. Sorne physicians advocate infiltrating corticosteroid loc ally, but well-documented proof of effectiveness is lacking. Both procedures run the risk of precipitating further bleeding, and the extent to which corticosteroid injection might retard healing has not been determined. The oral administration of proteolytic enzymes has been advocated, but as yet no firm conclusions can be drawn.
196
In managing deep muscle bruises, the important priority after bleeding has been controlled is to maintain muscle length and strength. This may be accomplished by having the patient contract the injured muscle isometrically and then perform active rangeof-motion exercises. Attempts to increase the range passive! y should be avoided, since they may invoke muscle spasm and cause further damage to muscle substance. Exercises should be carried out every two to three hours during the day, beginning with five repetitions of each and progressing gradually to 20. Pain can be relieved considerably by the use of ice massage loc ally be fore exercise is begun. When the injured extremity can go through a normal range of motion without pain, a program of exercises against progressively increasing resistance may be carried out until full muscle strength is restored. At this time use of the compression bandage is discontinued and the patient can gradually resume normal activity. The full range of joint motion should be maintained by continuing regular exercise for sorne weeks to prevent muscle shortening due to the graduai contraction of fibrous scar tissue at the injury site. Residual subcutaneous masses from organized hematomas are best left al one if they are not very large or pain fui. Over a period of months they will shrink and sorne will disappear. Massage over the injured part should be avoided, since it appears to exaggerate any tendency to myositis ossificans. This condition apparently occurs when injury stimulates mesenchymal cells in the muscle fascia to function as osteoblasts and to lay down real bone within the muscle. Soft-tissue x-ray examination will detect the presence of myositis ossificans as early as three weeks after injury. The inflammation must be allowed to run its course until stability is achieved, ie, no further bone formation is detected by x -ray. This may take from six weeks to six months. Attempts to excise the area before the process stabilizes may result in recurrence. Rehabilitation should proceed in
POSTGRADUATE MEDICINE
o
June 1976
o
Vol. 59
o
No. 6
problems solutions spite of the presence of inflammation, although the rigidity it gives to the muscle may make exercising more difficult.
Downloaded by [Australian Catholic University] at 14:35 09 August 2017
Summary
The first step in treating severe bruises is to control subcutaneous bleeding and thereby prevent the swelling that causes pain and disruption of soft tissues. Control is best accomplished by applying ice packs and compression to the site of injury and, if an extremity is involved, by elevating the limb above the level of the heart. This therapy should be maintained for at least 24 hours. A second priority is to maintain muscle length and strength. This can be done by instituting a program of active range-of-motion exercises followed by resistive exercises until full muscle strength is restored. • Address reprint requests to Editorial Department, POSTGRADUATE MEDICINE, 4530 W 77th St, Minneapolis, MN 55435.
Blbllography Abraham WM: Heat vs. cold therapy for the treatment of muscle injuries. Natl Athletic Trainers Assoc 9:177-179, 1974 Brewer BJ: Athletic injuries: Musculo-tendinous unit. In DePalma AF (Editor): Clinicat Orthopaedics, No. 23. Philadelphia, JB Lippincott, 1962, pp 30-27 Ellis M, Frank HG: Myositis ossificans traumatica: With special reference to the quadriceps femoris muscle. J Trauma 6:724-738, 1966 Glick JM: The use of therapeutic agents for musculo-skeletal injuries in athletics. In Committee on Medical Aspects of Sports (Editors): Medical Aspects of Sports. Chicago, American Medical Association, 1974, pp 29-31 Millar AP, Salmon J: Muscle tears. Aust Sports Med 2:35-42, 1967 Moore RJ Jr, Nicolette RL, Behnke RS: The therapeutic use of co1d (cryotherapy) in the care of athletic injuries. Natl Athletic Trainers Assoc 2:6-13, 1967 Peppard A: Myotonic muscle distress: A rationale for therapy. Natl Athletic Trainers Assoc 8:166-169, 1973 Rask MR, Lattig GJ: Traurnatic fibrosis of the rectus femoris muscle: Report of five cases and treatment. JAMA 221:268-269, 1972 Ryan AJ: Quadriceps strain, rupture and charlie horse. Med Sei Sports 1:106-111, 1969 Ryan AJ, Allman FL Jr (Editors): Sports Medicine. New York, Academie Press, 1974, chs 12, 13 Salmon J: Physiotherapy in hamstring injuries. Aust Sports Med 2:19-24, 1968 Smith ET: Myositis ossificans of the humerus (Biocker's disease). Tex Med 56:678-680, . 960
Vol. 511 • No. 8 • June 1978 • POSTGRADUATE IEDICifE
MayWe Help Vou? When you want consultation about current methods of diagnosis or treatment for a problem case, send us your query along with pertinent data. We will submit your question to our consultants and promptly forward the reply to you. Selected problems are published anonymously each month. Address queries to:
Problems/Solutions POSTGRADUATE MEDICINE 4530 W 77th St Minneapolis, MN 55435
197
