Ch 6 - Immediate Care of Acute Orthopedic Injuries

RICES acronyms

rest

ice

compression

elevation

stabilization

immediate care myths (4)

• ice dec swelling

• goal of immediate care is to dec inflammation

• inflammation and swelling are the same

• all injuries should be treated for the same amount of time

what is immediate care?

care given immediately after an acute orthopedic injury

acute orthopedic injury care 3 stages

• acute (0-4 days)

• subacute (5-14 days)

• postacute (> 14 days)

problems with the 3 stages

• range of acute care too wide, therefore must be subdivided

• care dictated by patient progress, not by specific time frames

NEW 3 stages

• acute

  • emergency care (eg CPR if needed)

  • immediate care (0-12 hours)

  • transition care (12 hours to 4 days)

• subacute

• postacute

why do we use RICES (5)

• total injury

• swelling

• pain

• further injury

• muscle spasm

Rice: rest (3)

• limits injury aggravation

• transition to “relative rest” (prevents de-conditioning)

• different from stabilization

rice: ice

limiting secondary injury and neural inhibition are more important than controlling swelling

2 ice/cold theories

• circulatory / dec blood flow theory

• dec secondary injury theory

flaw w dec blood flow theory

clotting occurs before tissue is cooled enough to substantially dec blood flow

dec secondary injury theory (5)

• cold dec cellular metabolism in viable cells

• dec O2 demand

• less secondary hypoxic injury

• less total injury

• less edema

cryotherapy focus on dec secondary injury theory

NO effect on primary traumatic injury or hemorrhaging but helps secondary injury and edema

metabolism and cooling have a

direct relationship

• more cooling = greater dec in metabolism

why don’t we apply heat immediately

heat inc metabolism = causes more secondary injury

cryotherapy and swelling

• cold dec edema NOT hemorrhage

• cold limits edema formation

rice: compression

controls edema beyond normal volume

• apply constantly until swelling is over

rices: elevation

dec capillary hydrostatic pressure

ideally 6” above heart level elevation

what is the major factor in forcing fluid out of the capillary

capillary hydrostatic pressure

rices: stabilization (3)

• controls neural inhibition

• therefore intended function does not occur

• dec pain-spasm-pain cycle

neural inhibition def

process in which neural pathway. is blocked so impulses can’t pass (dec in pain)

what is the goal of cold?

to dec tissue metabolism (state of temp hibernation)

conduction: physiology of heat transfer

exchange of energy (heat) b/w 2 substances in contact w each other

• moves from body of higher energy to body of lower energy until equilibrium is reached

rate of conduction is influenced by (7)

• temp differential b/w body and modality

• regeneration of body heat and modality cooling

• heat storage capacity of cold modality

• size of cold modality

• amount of tissue in contact

• length of application

• individual variability

heat storage capacity (2)

• specific heat

• latent heat of fusion

specific heat

amount of heat energy required to raise 1 kg of substance 1 C

• the greater the specific energy of substance, the more heat it will withdrawl

latent heat of fusion

amount of heat energy needed to convert a substance from a solid state to a liquid state w/o changing its temp

why is crushed ice pack better than gel pack?

• gel pack do NOT freeze solid = no phase change

• crushed ice pack DOES have phase change due to heat of fusion

temp changes resulting from cold pack application (4)

• surface temp → compression wrap over cold pack, activity b/w applications

• tissue temp → depends on depth and type of tissue

• deeper tissue temps → rewarming takes hours

• articular temp → @ joint, amount of adipose tissue

rewarming after application (3)

• activity level before cryotherapy

• amount of heat removed from body during application

• amount of heat available to rewarm area

factors that affect tissue cooling (6)

• type of cold pack

• duration of application

• size of cold pack

• amount of tissue in contact w pack

• depth of target tissue

• method of application

4 general types of cold pack

• crushed ice

• gel

• artificial ice

• chemical

which cold pack is the MOST effective

crushed ice due to heat of fusion, don’t melt for hours if in cooler

what are the least effective cold packs

• gel pack → cool level is dangerous, no heat of fusion

• artificial ice → better than gel but no as good b/c of insulation from nylon cover

• chemical → least cooling, no recommended

• frozen peas → better than nothing but little phase change avoid if possible

cold: application protocol

apply a barrier b/w the cold pack and the skin

cold: length of application

• intermittent 30-60 min every 2 hours

• depth of target tissue

• adipose tissue → leave on longer

cold: duration of therapy

• severity of injury

• transition from RICES to cryotherapy techniques involving exercise

prevent: dec metabolism

cold effective

remove: stimulate lymph flow

cold not effective

removing swelling (2)

• must stimulate lymph flow

• requires compression

  • massage

  • lymphedema pump

  • active exercise (ms pump)

stretch elastic wraps are

~75% as they are applied

cryotherapy: contraindications (8)

• raynaud’s / vasospastic diseases

• cold hypersensitivity

• circulatory insufficiency

• anesthetic skin

• advanced diabetes

• lupus

• presence of cancer

• open wounds or lesions

vasospastic disorders (3)

• livedo retinacularis

• raynaud’s phenomenon

• acrocyanosis

livedo retinacularis

semi-permanent bluish mottling of the skin, hands, and legs when exposed to cold

raynaud’s phenomenon

small arteries and arterioles constrict in the extremities resulting in pallor/cyanosis

• occurs in fingers and toes

acrocyanosis

painless and persistent coldness and cyanosis of the distal parts of the extremities

cold hypersensitivity (3)

• cold hemoglobinuria

• purpura

• cold erythema

cold hemoglobinuria

free hemoglobin in the urine (blood breaks down in the vessels)

purpura

hemorrhage into skin and mucous membranes (abnormal proteins in the blood)

cold erythema

redness, congenital, abnormal response to cooling characterized by severe pain, ms spasms, sweating

precautions to cold therapy (6)

• near eyes

• avoid treating large areas w having: cardiac/resp involvement, hypertension

• never apply longer than 1 hour continuously since this may cause frostbite

• no cold packs directly over the skin

• careful w ice over bony protuberances

• careful w children and elderly

5 Step Application for Immediate Care

• foundation

• preapplication tasks

• application parameters

• postapplication tasks

• maintenance

foundations checklist (7)

• definition

• effects → dec metabolism in injured tissue

• advantages → dec swelling = less pain = less healing needed

• disadvantages → can be messy, only good for first 5-10 mins

• indications → soft tissue injury

• contraindications → cold allergy, hypersensitive to cold

• precautions → do not apply for more than 60 mins and no less than -17 C

Preapplication Tasks checklist (3)

• selecting the proper modality

• preparing the patient physically

• preparing the equipment

application parameters procedures (7)

• ice bag

• elastic wrap

• stabilize

• elevate → 6” or so above heart

• dosage → extends 2-3” beyond injury

• duration → 20-60 minutes depending on injury & skinfold

• frequency of application

postapplication tasks (3)

• replace equipment/clean up area

• give patient written instructions

• record treatment and unique patient response to tx

maintenance (2)

• keep ice machine in good repair

• replace elastic wraps as they deterioriate