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Overview of Sprains and Other Soft Tissue Injuries
Treatment of Sprains and Other Soft Tissue Injuries
Treatment of associated injuries Reduction as indicated, splinting, and analgesia RICE (rest, ice, compression, and elevation) or PRICE (including protection) as indicated Usually immobilization Sometimes surgery Serious associated problems, if present, are treated first. Treatment of hemorrhagic shock is treated immediately. Injuries to arteries are surgically repaired unless they affect only small arteries with good collateral circulation. Severed nerves are surgically repaired; for neuropraxia and axonotmesis, initial treatment is usually observation, supportive measures, and sometimes physical therapy. Suspected open fractures or dislocations require Sterile wound dressings Tetanus prophylaxis Broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside), which should be initiated within one hour of arrival to the emergency department Surgery to irrigate and debride them (and thus prevent infection). Most moderate and severe injuries, particularly grossly unstable ones, are immobilized immediately by splinting (immobilization with a nonrigid or noncircumferential device) to decrease pain and to prevent further injury to soft tissues by unstable injuries. Pain is treated as soon as possible; sometimes Opioid Analgesics are required. After initial treatment, soft-tissue injuries are treated symptomatically and are immobilized as indicated. Many 3rd-degree sprains and tendon tears require surgical repair. Patients who have soft-tissue injuries, with or without other musculoskeletal injuries, may benefit from PRICE (protection, rest, ice, compression, elevation), although this practice is not supported by strong evidence. Protectionhelps prevent further injury. It may involve limiting the use of an injured part, applying a splint or cast, and/or using crutches. Restmay prevent further injury and speed healing. Iceandcompressionmay minimize swelling and pain. Ice is enclosed in a plastic bag or towel and applied intermittently during the first 24 to 48 hours (for 15 to 20 minutes, as often as possible). Injuries can be compressed with a splint, an elastic bandage, or, for certain injuries likely to cause severe swelling, a Jones compression dressing. The Jones dressing is 4 layers; layers 1 (the innermost) and 3 are cotton batting, and layers 2 and 4 are elastic bandages. Elevatingthe injured limb above the heart for the first 2 days, ideally in a position that provides an uninterrupted downward path, allows gravity to help drain edema fluid and minimize swelling. After 48 hours, periodic application of warmth (eg, a heating pad) for 15 to 20 minutes may relieve pain and speed healing. Immobilization decreases pain and facilitates healing by preventing further injury. First-degree sprains are immobilized briefly if at all. Early mobilization is best. Mild 2nd-degree sprains are often immobilized with a sling or splint for a few days. Severe 2nd-degree and some 3rd-degree sprains and tendon tears are immobilized for days or weeks, sometimes with a cast. Many 3rd-degree sprains require surgery; usually, immobilization is only adjunctive therapy. is usually used for injuries that require weeks of immobilization. Rarely, swelling under a cast is severe enough to contribute to Compartment Syndrome . If clinicians suspect severe swelling under a cast, the cast (and all padding) is cut open from end to end medially and laterally (bivalved). Patients with casts should be given written instructions, including the following: Keep the cast dry. Never put an object inside the cast. Inspect the cast’s edges and skin around the cast every day, and report any red or sore areas. Pad any rough edges with soft adhesive tape, cloth, or other soft material to prevent the cast’s edges from injuring the skin. When resting, position the cast carefully, possibly using a small pillow or pad, to prevent the edge from pinching or digging into the skin. Elevate the cast whenever possible to control swelling. Seek medical care immediately if pain persists or the cast feels excessively tight. Seek medical care immediately if an odor emanates from within the cast or if a fever, which may indicate infection, develops. Seek care immediately for progressively worsening pain or any new numbness or weakness. Good hygiene is important. Asplint(see figure) can be used to immobilize some stable injuries, including some suspected but unproven fractures, rapidly healing fractures, sprains, and other injuries that require immobilization for several days or less. A splint is noncircumferential; thus, it enables patients to apply ice and to move more than a cast does. Also, it allows for some swelling, so it does not contribute to compartment syndrome. Some injuries that ultimately require casting are immobilized initially with a splint until most of the swelling resolves. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. Aslingprovides some degree of support and limits mobility; it can be useful for injuries that are adversely affected by complete immobilization (eg, for shoulder injuries, which, if completely immobilized, can rapidly lead to adhesive capsulitis [frozen shoulder]). Aswathe(a piece of cloth or a strap) may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part. Prolonged immobilization (> 3 to 4 weeks for young adults) of a joint can cause stiffness, contractures, and muscle atrophy. These complications may develop rapidly and may be permanent, particularly in older people. Some rapidly healing injuries are best treated with resumption of active motion within the first few days or weeks; such early mobilization may minimize contractures and muscle atrophy, thus accelerating functional recovery. Physical therapists can advise patients as to what they can do during immobilization to maintain as much function as possible (eg, elbow, wrist, and hand range-of-motion exercises if the shoulder is immobilized). After immobilization, physical therapists can help patients regain or improve range of motion and muscle strength and can provide exercises to strengthen and stabilize the injured joint and thus help prevent recurrence and long-term impairment. Early range-of-motion exercises are important for all patients, especially those age > 40 years. More complications and morbidity can occur for immobilized patients as they age, particularly for anyone > 40 years old. Many 3rd-degree sprains and tendon tears require surgical repair. Arthroscopic surgeryis sometimes used. This procedure is used most often to repair ligaments or menisci in the knee. 