Presentation
The patient has fallen, has been thrown against an object or has been struck at a site where now there is point tenderness, swelling, ecchymosis, hematoma, or pain with use. On physical examination, there is no loss of function of muscles and tendons (beyond mild splinting because of pain), no instability of bones and ligaments, and no crepitus or tenderness produced by remote stress (such as weight-bearing on the leg or manual flexing of a rib).
What to do:
Take a thorough history to ascertain the mechanism of injury and perform a complete examination to document structural integrity and intact function.
Reserve x rays for possible foreign bodies and bony injury. Fractures are uncommon after a direct blow, but are suggested by pain with remote percussion or stressing of bone or an underlying deformity or crepitus. The yield is very low when x rays are ordered on the basis of pain and swelling alone.
Explain to the patient that swelling will peak in 1 day, then resolve gradually, and that swelling, stiffness and pain may be reduced by good treatment during the first 1-2 days.
Prescribe:
resting the affected part,immobilization (the ultimate in rest, best achieved with a splint),elevation of the affected part (ideally, above the level of the heart), and
cold (usually an ice bag, wrapped in a towel, applied to the injury for 10-20 minutes per hour for the first 24 hours).
Explain to the patient the late migration and color change of ecchymoses, so that green or purple discoloration appearing farther down the limb a week after the injury does not frighten him into thinking he has another injury.
Large intramuscular hematomas (especially of the anterior thigh) may require drainage or orthopedic consultation.
Arrange for re-evaluation and followup if there is any continued or increasing discomfort.
What not to do:
Do not apply an elastic bandage to the middle of a limb, where it may act as a tourniquet. Include all of the distal limb in the wrapping if a compression dressing is necessary.
Do not confuse patients with instructions for application of heat and exercises to prevent stiffness and atrophy. Concentrate on the here-and-now therapy of the acute injury; namely, rest, immobilization, elevation, and cold: all designed to decrease acute edema. Leave other instructions to followup and . physical therapy consultants. Patients who confuse today's correct therapy with next week's can complicate their problem.
Do not take for granted that all of your patients understand rest, immobilization, elevation, and cold. Walking on a fresh foot injury or soaking it for long periods in ice water or Epsom salts are not usually therapeutic.
Discussion
The acute therapy of contusions concentrates upon reduction of the acute edema, and all other components of treatment are postponed for 3-4 days, until the inflammation and edema are reduced. Patients need to know this time course, and must understand that the more the swelling can be reduced, the sooner injuries can heal, function return and pain decrease. Edema of hands and feet is especially slow to resolve, because these structures usually hang in a dependent position, and require much modification of activity to rest.
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