© 2008 lww chapter 5. immediate care of acute orthopedic injuries
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© 2008 LWW
RICESRICES• The prescription for immediate care• RICES
– Rest– Ice– Compression– Elevation– Stabilization
© 2008 LWW
Immediate Care MythsImmediate Care Myths• Acute care and immediate care are the same.• Ice decreases swelling.• The goal of immediate care is to decrease
inflammation.• The purpose of ice is to decrease hemorrhaging.• Inflammation and swelling are the same.• Ice should be applied for 20 min during
immediate care. • All injuries should be treated for the same
amount of time.
© 2008 LWW
What Is Immediate Care?What Is Immediate Care?
• Care given immediately after an acute orthopedic injury
• Subset of acute orthopedic injury care
© 2008 LWW
Acute Orthopedic Injury CareAcute Orthopedic Injury Care
Typically three stages• Acute (0–4 days) • Subacute (5–14 days) • Postacute (>14 days)
© 2008 LWW
Acute Orthopedic Injury Care (cont.)Acute Orthopedic Injury Care (cont.)
Problems with the typical three stages• Range of acute care too wide
– Treatment 10 min after injury is not the same as that needed 3 days after the injury.
– Acute care, therefore, must be subdivided. • Injuries heal at different rates
– Type and severity of injury– Individual patient differences
• Care dictated by patient progress, not by specific time frames
© 2008 LWW
Acute Orthopedic Injury Care (cont.)Acute Orthopedic Injury Care (cont.)
New three stages• Acute (0–4 days)
– Emergency care (e.g., CPR, if needed)– Immediate care (0–12 hr)– Transition care (12 hr to 4 days)
• Subacute (5–14 days), • Postacute (>14 days)
© 2008 LWW
Why RICES?Why RICES?
• To limit (decrease):– Total injury– Swelling– Pain– Further injury– Muscle spasm– Inflammation? NONO
© 2008 LWW
Rest: Why?Rest: Why?
Limits injury aggravation• Should be total during
immediate care• Transition to “relative” rest• Different from, but related
to, stabilization
© 2008 LWW
Ice/Cold: Why?Ice/Cold: Why?
• Most think it’s to control swelling.– Important but only part of immediate care
• Limiting secondary injury and neural inhibition are more important than controlling swelling.
© 2008 LWW
Ice/Cold: Why? (cont.)Ice/Cold: Why? (cont.)Ice/Cold: Why? (cont.)Ice/Cold: Why? (cont.)
• Two theories– Circulatory or decreased blood flow
theory– Decreased secondary injury theory
© 2008 LWW
Decreased Blood Flow TheoryDecreased Blood Flow Theory• Older, traditional theory• Cold decreases blood flow.• Logic of theory
– Cold causes vasoconstriction– Which decreases blood flow and therefore– Decreases hemorrhaging and therefore– Swelling is reduced
• Flaw: Clotting occurs before tissue is cooled enough to substantially decrease blood flow.
© 2008 LWW
Decreased Secondary Injury TheoryDecreased Secondary Injury Theory• History
– First proposed in 1976
– Refined in 1985– Tweaked in
2002
• Flaw:– Cold application
has little effect on hemorrhaging.
• Limits amount of secondary injury and, therefore, edema.
© 2008 LWW
Decreased Secondary Injury Theory (cont.)Decreased Secondary Injury Theory (cont.)
• Cold decreases cellular metabolism in viable cells, thus– Reduces oxygen demand
(consumption)– Less secondary hypoxic injury– Less total injury– Less free protein generated by
phagocytosis– Less edema
© 2008 LWW
Metabolism and CoolingMetabolism and Cooling• Direct relationship
– More cooling means greater decrease in metabolism
© 2008 LWW
Metabolism and Cooling (cont.)Metabolism and Cooling (cont.)
• Heat increases metabolism.– Causes more secondary injury
© 2008 LWW
Cryotherapy and SwellingCryotherapy and Swelling
• Decreased edema, not hemorrhage– Most occurs hours after injury, as free
protein accumulates from phagocytosis
• Cold reduces edema formation– By preventing secondary injury and thus
less free protein accumulation
© 2008 LWW
Compression: Why?Compression: Why?• Controls edema beyond normal volume
(i.e., after tissue spaces are filled)• Apply constantly until swelling is over.
© 2008 LWW
Stabilization: Why?Stabilization: Why?
Controls neural inhibition• Process in which neural pathway is
blocked so impulses cannot pass– Intended function does not occur.
• Can be partial so function is diminished or total so function is abolished temporarily
© 2008 LWW
Stabilization: Why? (cont.)Stabilization: Why? (cont.)Allows muscles to relax, thus• Decreases pain–spasm–pain cycle • Numerous braces and splints for
stabilization
© 2008 LWW
RICES Theory: RevisitedRICES Theory: Revisited
• Rest
• Ice• Compression• Elevation• Stabilization
© 2008 LWW
What Is the Goal of Cold?What Is the Goal of Cold?• Decrease tissue metabolism!• More cooling means greater decrease
in metabolism.
© 2008 LWW
Does It Matter How You Apply Does It Matter How You Apply Cold?Cold?Does It Matter How You Apply Does It Matter How You Apply Cold?Cold?• Yes
– Great differences in tissue cooling
© 2008 LWW
Cryotherapy Physics and Physiology Cryotherapy Physics and Physiology
• Cold does not exist; it is not a physical substance.
• Cold is absence of heat.
© 2008 LWW
Physiology of Heat TransferPhysiology of Heat Transfer
Conduction• Exchange of energy (heat) between two
substances in contact with each other • Heat moves from body of higher energy to
body of lower energy.• Causes warmer body to cool and cooler body
to warm, until they reach equilibrium
© 2008 LWW
Rate of ConductionRate of Conduction• Temperature differential between body and
modality• Regeneration of body heat and modality
cooling• Heat storage capacity of cold modality• Size of the cold modality• Amount of tissue in contact with pack• Length of application• Individual variability
© 2008 LWW
Heat Storage Capacity (cont.)Heat Storage Capacity (cont.)Specific heat• Amount of heat energy required to raise 1
kg of a substance 1°C– Ice = 0.5 cal/g– Water = 1 cal/g
© 2008 LWW
Heat Storage Capacity (cont.)Heat Storage Capacity (cont.)
• Latent heat of fusion– Amount of heat energy needed to
convert a substance from a solid state to a liquid state without changing its temperature
– Phase change– Ice to water = 80 cal/kg
© 2008 LWW
Heat Storage Capacity (cont.)Heat Storage Capacity (cont.)
Crushed ice pack better than gel pack• Gel pack ~22 kcal
– Water from −17°C to 5°C
• Crushed ice pack ~ 86 kcal– Ice from −1°C to 0°C, – Heat of fusion – Water from 0°C to 5°C
© 2008 LWW
Heat Storage Capacity (cont.)Heat Storage Capacity (cont.)
Crushed ice pack better than gel pack
© 2008 LWW
Temperature Changes Resulting from Cold Pack ApplicationTemperature Changes Resulting from Cold Pack Application
• Surface temperature– Repeated applications
• Time ratio• Activity between applications
(shower)– Compression wrap over cold pack
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application, (cont.)Temperature Changes Resulting from Cold Pack Application, (cont.)
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application (cont.)
Temperature Changes Resulting from Cold Pack Application (cont.)
• Tissue temperature– Depends on depth and type of
tissue– Delayed response– Continues to decrease after
application
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application (cont.)Temperature Changes Resulting from Cold Pack Application (cont.)
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application (cont.)
Temperature Changes Resulting from Cold Pack Application (cont.)
• Tissue temperature– Amount of adipose tissue– Rewarming takes hours
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application (cont.)Temperature Changes Resulting from Cold Pack Application (cont.)
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application (cont.)
Temperature Changes Resulting from Cold Pack Application (cont.)
• Articular temperature– Similar to tissue temperature– Delayed response– Continues to decrease after application– Amount of adipose tissue
© 2008 LWW
Temperature Changes Resulting from Cold Pack Application (cont.)
Temperature Changes Resulting from Cold Pack Application (cont.)
Rewarming after application• Depth of tissue• Amount of heat available to rewarm area:
function of circulation and environmental temperature.
• Activity level before cryotherapy and palmer• Amount of heat removed from body during
application (i.e., magnitude and duration of cold exposure)
© 2008 LWW
Cryotherapy: Application Principles Cryotherapy: Application Principles
• Tissue cooling depends on – Cold modality used– How modality is applied
• Many protocols suggest– Length – Frequency – Duration
© 2008 LWW
Factors That Effect Tissue CoolingFactors That Effect Tissue Cooling• Type of cold pack
– Heat of fusion
• Duration of application– Longer the
application• More cooling• Slower rewarming
• Size of cold pack– Larger cold pack,
more cooling
• Amount of tissue in contact with pack– More tissue
contact, more cooling
© 2008 LWW
Factors That Effect Tissue Cooling (cont.)Factors That Effect Tissue Cooling (cont.)
• Depth of target tissue– Deeper target,
less cooling
• Type of cold pack
• Method of application – On skin or over a
towel or wrap– Compression over
pack (per Merrick)
© 2008 LWW
Types of Cold PacksTypes of Cold Packs
Four general types:• Crushed ice• Gel (Chattanooga,
Cramer)• Artificial ice
– Water in vinyl (Dura*Kold)
• Chemical– Double bags,
crushable – Powder types
© 2008 LWW
Types of Cold Packs (cont.)Types of Cold Packs (cont.)
Crushed ice• Most effective because of heat of fusion• Excellent for on-the-field use because
they don’t melt for hours stored if in insulated cooler
• Should not be used if kept in a freezer (too cold)
© 2008 LWW
Types of Cold Packs (cont.)Types of Cold Packs (cont.)
Gel pack• Water, alcohol, and gel substance• Cooled to ~1°F (−17°C), so dangerous• Not as effective as crushed ice packs
(no heat of fusion)• Even less effective if wrapped in towel
© 2008 LWW
Types of Cold Packs (cont.)Types of Cold Packs (cont.)Gel pack• Dangerous if applied directly on skin
© 2008 LWW
Types of Cold Packs (cont.)Types of Cold Packs (cont.)
Artificial ice • Water in vinyl pouches, surrounded by
nylon cover (Dura*Kold)• Better than gel because of heat of
fusion• Not as good crushed ice because of
insulation from nylon cover• Good for home use
© 2008 LWW
Types of Cold Packs (cont.)Types of Cold Packs (cont.)
Chemical: double bags, crushable• Chemical reaction when inner bag is
crushed and contents react with outer chemicals
• Least cooling• Not recommended
© 2008 LWW
Cold: Application ProtocolCold: Application Protocol• Apply directly to skin, not over a towel
or elastic wrap – Except for gel packs– Except for crushed ice from freezer
© 2008 LWW
Cold: Application Protocol (cont.)Cold: Application Protocol (cont.)
– Insulation decreases effectiveness
© 2008 LWW
Cold: Cold: Length of ApplicationCold: Cold: Length of Application• Intermittent,
30–60 min every 2 hr
• Depth of target tissue
• Adipose tissue
© 2008 LWW
Cold: Cold: Duration of TherapyCold: Cold: Duration of Therapy
• Severity of injury• Transition from RICES to cryotherapy
techniques involving exercise
© 2008 LWW
Preventing vs. Removing SwellingPreventing vs. Removing Swelling
• Preventing secondary injury vs. removing free protein from extracellular spaces
• Prevent: decrease metabolism– Cold effective
• Remove: stimulate lymph flow– Cold is a waste of time
© 2008 LWW
Preventing vs. Removing Swelling (cont.)Preventing vs. Removing Swelling (cont.)• Removing free protein
from extracellular spaces
– Must stimulate lymph flow
– Requires intermittent compression• Massage• Lymphedema pump• Active exercise (muscle
pump)
© 2008 LWW
Compression: Application PrinciplesCompression: Application Principles
• Elastic wraps preferred– Plastic wraps not as effective
© 2008 LWW
Compression: Application Principles (cont.)Compression: Application Principles (cont.)• Apply elastic
wraps over ice pack
– Compression same as if wrap applied first
© 2008 LWW
Compression: Application Principles (cont.)Compression: Application Principles (cont.)
• Stretch elastic wraps ~75% as they are applied.
© 2008 LWW
Cryotherapy: Contraindications and Precautions
Cryotherapy: Contraindications and Precautions
Cold is dangerous if • Too cold or too long• Under excessive compression• Patient suffers from some specific diseases,
such as – Raynaud– Cold hypersensitivity– Cold urticaria
© 2008 LWW
Five-Step Application for Immediate CareFive-Step Application for Immediate Care
• Foundation• Preapplication tasks• Application parameters• Postapplication tasks• Maintenance
© 2008 LWW
Step 1. FoundationStep 1. Foundation
• Definition• Effects• Advantages• Disadvantages• Indications• Contraindications• Precautions
© 2008 LWW
EffectsEffects Ice decreases metabolism in the injured
tissue. Decreases the need for oxygen Decreases secondary hypoxic injury
© 2008 LWW
Effects (cont.)Effects (cont.)
Compression and elevation Counteract edema and result in a decrease in
swelling
© 2008 LWW
Effects (cont.)Effects (cont.)
StabilizationStabilization Allows musculature around the injury to
relax Along with ice, limits pain–spasm–pain
cycle
© 2008 LWW
AdvantagesAdvantages
Less total tissue damage means less healing needed.
Decreased swelling means less pain. Decreased pain means less neural
inhibition. Ice is relatively inexpensive.
© 2008 LWW
DisadvantagesDisadvantages
Effectiveness diminishes with time. Full effects only if applied within 5–10
min after injury
© 2008 LWW
ContraindicationsContraindications
Do not use with a person who is
Hypersensitive to cold Allergic to cold Has circulatory abnormalities
© 2008 LWW
PrecautionsPrecautions
Ice packs not directly on skin continuously >60 min
Cold packs cooled to or less than −17°C(0°F) should not be applied directly to the skin.
© 2008 LWW
Step 2. Preapplication TasksStep 2. Preapplication Tasks
Selecting the proper modality Preparing the patient physically Preparing the patient physically Preparing the equipment
© 2008 LWW
Selecting the Proper ModalitySelecting the Proper Modality
Evaluate the injury or problemDetermine the treatment goalsCheck for contraindicationsHypersensitive to cold?
© 2008 LWW
Preparing the Patient PhysicallyPreparing the Patient Physically
Remove overlying clothing. Remove braces and bandages, as
necessary. Place patient in a comfortable position
and so that the injured area is elevated.
© 2008 LWW
Preparing the Patient PsychologicallyPreparing the Patient Psychologically
Pain and frustration from the injury are usually the biggest problems.
Reassure the athlete. Warn about precautions.
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Preparing the EquipmentPreparing the Equipment Prepare the ice
pack Crushed ice in a
plastic bag Big enough to
extend 2–3 in. beyond injury
Evacuate as much air as possible from the bag.
Tie a knot in bag.
© 2008 LWW
Preparing the Equipment (cont.)Preparing the Equipment (cont.)
Elastic wraps Prefer 6 in., never <4 in. Double length or multiple
for large areas Splint or sling,
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Step 3. Application ParametersStep 3. Application Parameters
• Procedures– Ice bag– Elastic wrap– Stabilize– Elevate– Dosage– Duration– Frequency of application
© 2008 LWW
Ice BagIce Bag
Place directly on skin Center over middle of injury Shape to general contour
of body part
,
© 2008 LWW
Elastic WrapElastic Wrap
,
Apply snugly, but not too tightly (stretch to ~75% of length).
Cover the entire area. Secure with clips, tape, or tuck. Wear constantly for 20–24 hr, except
when changing ice bag No Flexi-Wrap, no compression
© 2008 LWW
StabilizeStabilize
Splint, sling, or brace Goal is total muscle relaxation. Sling for upper extremity
injuries, if muscle guarding occurs
Crutches for lower extremity injuries, if walking causes pain and/or limping
© 2008 LWW
DosageDosage
Ice pack extends 2–3 inches beyond injury.
Compression extends 2–3 inches beyond ice pack.,
© 2008 LWW
Length of ApplicationLength of Application
Ice bag, intermittently 20–60 min depends on injury and skinfold
20 min, finger 30 min ankle, arm 45 min, thigh +1 min per millimeter of skinfold
Compression and elevation constantly Rest and stabilization until pain free
,
© 2008 LWW
Frequency of ApplicationFrequency of Application
Ice 5–10 min after injury Second application 30–60 min later, after
shower and go home Every 2 hr thereafter (don’t stay up into
night) Rest, compression, elevation, and
stabilization constantly,
© 2008 LWW
Step 4. Postapplication TasksStep 4. Postapplication Tasks Replace equipment/clean up area
Drain water and ice from ice pack (save the plastic bag for another use).
Return cold pack to refrigeration unit. Give patient written instructions
Time of next appointment Rest injury Time for reapplication of ice Phone number for emergency
Record treatment and unique patient response to treatment
© 2008 LWW
Step 5. MaintenanceStep 5. Maintenance
Keep ice machine in good repair. Replace elastic wraps as they
deteriorate.
© 2008 LWW
Crutch UseCrutch Use
Who? Any patient unable to walk without a limp
Why? Crutches facilitate proper gait by using arms
to substitute for, or supplement, leg power Failure to use crutches may result in:
Delayed healing Permanent abnormal gait
© 2008 LWW
Crutch Use (cont.)Crutch Use (cont.)
Proper use requires• Proper fitting of crutches• Selecting the appropriate gait• Instructing patient to walk properly• Observing the patient practice the gait• Periodic reevaluating to make sure patient is
using crutches properly
© 2008 LWW
Crutch Use (cont.)Crutch Use (cont.)
Crutch fitting• Adjust length so 2–3 inches between
top and axilla.• Adjust hand piece
so elbow is flexed 30°.
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Crutch Use (cont.)Crutch Use (cont.)
Select gait• Swing, if all weight off• 3-point for partial weight bearing
– Use this as much as possible– Gradually increase weight on foot
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Crutch Use (cont.)Crutch Use (cont.)
Walking instructions• Proper gait• Amount of weight on foot• Up and down stairs
– The phrase “the good go up to heaven, the bad down to hell” may help you remember which foot or leg goes first when walking up and down stairs.
© 2008 LWW
Crutch Use (cont.)Crutch Use (cont.)
Observe patient walking• Proper gait• Adjust if necessary
Periodic reevaluation
© 2008 LWW
Medicated Ice CupsMedicated Ice Cups
• For skin abrasions
– Clean wound– Apply antiseptic– Cool tissue
© 2008 LWW
Medicated Ice Cups (cont.)Medicated Ice Cups (cont.)Materials • 4 2-oz. disposable cups• 1 oz. of 2% lidocaine• 3 oz. of 10% povidine-iodine• 3 oz. of distilled or boiled water• Plastic stir sticks (handle)• Adhesive tape (to secure stir sticks in center
of cup
Mix together and pour into cups. Secure sticks in center of each cup with tape. Label and freeze overnight.
© 2008 LWW
Medicated Ice Cups (cont.)Medicated Ice Cups (cont.)
Medicated ice massage • Seek physician advice and approval before
using. • Hold by stir stick and roll the ice back and
forth along lacerated skin ~10 min. • As ice melts, medicines flow into wound. • Débride the area (remove foreign materials). • Treat and protect the area as any open
wound, emphasizing sterility. • Apply an ice pack for 20–30 min each hour
and compression constantly
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