CH. 67 pg. 1639-1640 (Sprains and Strains)

Soft Tissue Injuries

Soft tissue injuries include sprains, strains, dislocations, and subluxations. They usually result from trauma. As more people have become involved in fitness programs or sports, the incidence of soft tissue injuries has increased.

Common Sports-Related Injuries

• Sports injuries that often result in a visit to the emergency department (ED) for younger patients include:

  • Sprains

  • Strains

  • Growth plate injuries

  • Repetitive motion injuries.

Sprains and Strains

Sprains and strains often result from abnormal stretching or twisting forces during vigorous activities. These injuries tend to occur around joints and in the spinal muscles.

Sprains

• A sprain is an injury to the ligaments surrounding a joint, usually caused by a wrenching or twisting motion. Most sprains occur in the ankle, wrist, and knee joints.

• Classification:

  • First-degree (mild): Involves tears in only a few fibers, with mild tenderness and minimal swelling.

  • Second-degree (moderate): Results in partial disruption of the involved tissue with more swelling and tenderness.

  • Third-degree (severe): Is a complete tear of the ligament with moderate to severe swelling.

Strains

• A strain is an excessive stretching of a muscle and its fascial sheath, often involving the tendon. Most strains occur in the large muscle groups, including the lower back, calf, and hamstrings.

• Classification:

  • First degree (mild): Slightly pulled muscle.

  • Second degree (moderate): Moderately torn muscle.

  • Third degree (severe): Severely torn or ruptured muscle; a defect in the muscle may be apparent or palpable through the skin.

Manifestations

• Common manifestations of sprains and strains include:

  • Pain

  • Edema

  • Decreased function

  • Bruising

• Continued use of the joint, tendon, or ligament exacerbates pain, and edema develops due to the local inflammatory response.

Recovery and Complications

• Mild sprains and strains are usually self-limiting, with full function generally returning within 3 to 6 weeks.

• X-rays may be performed to rule out fractures.

• Severe sprains can lead to avulsion fractures, where the ligament pulls loose a fragment of bone, potentially causing joint instability, subluxation, or dislocation.

• At the time of injury, hemarthrosis (bleeding into a joint space) or disruption of the synovial lining may occur. Severe strains might require surgical repair of the muscle, tendon, or surrounding fascia.

Preventing Musculoskeletal Problems in Older Adults

To prevent musculoskeletal problems, include the following instructions when teaching older adults and their caregivers:

1. Use ramps in buildings and at street corners instead of steps to prevent falls.

2. Remove throw rugs from the home.

3. Treat pain and discomfort from osteoarthritis.

   • Rest in positions that decrease discomfort.

   • Use medication as prescribed for pain.

4. Use a walker or cane to help prevent falls.

5. Eat the amount and kind of foods needed to prevent weight gain. Obesity adds stress to joints, which may predispose to osteoarthritis.

6. Get regular and frequent exercise.

   • Activities of Daily Living (ADLs) provide range-of-motion exercises. Tai Chi may be helpful.

   • Hobbies (e.g., jigsaw puzzles, needlework, model building) exercise finger joints and prevent stiffness.

   • Do daily weight-bearing exercise (e.g., walking) to improve bone health.

7. Use shoes with good support for safety and comfort.

8. Avoid sudden changes in position. Rise slowly to a standing position to prevent dizziness, falls, and fractures.

9. Do not walk on uneven surfaces and wet floors.

Nursing Management: Sprains and Strains

Implementation

• Health Promotion: Warming up muscles before exercising and vigorous activity, followed by stretching, may significantly reduce the risk for sprains and strains.

• Strength Exercises: Important for building muscle strength and bone density. Involves working against resistance.

• Balance Exercises: May overlap with some strength exercises and are essential for fall prevention.

• Endurance Exercises: Should begin at a low level of effort and progress gradually to a moderate level.

Promoting Population Health

Health Impact of Physical Activity

• Helps with weight management.

• Increases lean muscle and decreases body fat.

• Helps maintain and improve bone mass.

• Increases muscle strength, flexibility, and endurance.

• Helps prevent high blood pressure.

• Reduces the risk for heart disease, diabetes, and colon cancer.

• Enhances sense of well-being and reduces risk for depression.

Acute Care

If an injury occurs, immediate care focuses on:

1. Stopping the activity and limiting movement to the injured part.

2. Applying ice packs to the injured area.

3. Compressing the involved area.

4. Elevating the extremity.

5. Providing analgesia as needed (Table 67.3).

Most sprains and strains are treated in the outpatient setting.

RICE (Rest, Ice, Compression, Elevation)

RICE may decrease local inflammation and pain for most musculoskeletal injuries. Movement should be restricted with the extremity rested as soon as pain is felt. Unless the injury is severe, prolonged rest is usually not needed.

Cold Therapy (Cryotherapy)

There are several forms of cold therapy. Cold causes vasoconstriction in the soft tissue and reduces the transmission and perception of nerve pain impulses. These changes also reduce muscle spasms, inflammation, and edema. Cold is most useful when applied immediately after an injury and used for 24 to 28 hours. Apply ice for no more than 20 to 30 minutes at a time and do not apply it directly to the skin.

Compression

Compression helps decrease edema and pain. An elastic compression bandage is often used and should be wrapped starting distally (at the point farthest from the trunk) and progress proximally (toward the trunk). The bandage is too tight if there is numbness or tingling below the area of compression, or if pain or more swelling occurs beyond the edge of the bandage. Leave the bandage in place for 30 minutes, then remove it for 15 minutes. An elastic wrap may provide extra support during training, athletic, and work activities.

Elevation

Elevate the injured part above heart level, even during sleep, for 24 to 48 hours to help mobilize excess fluid from the area and prevent further edema.

Mild analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to manage discomfort.

After the Acute Phase

After the acute phase (usually 24 to 48 hours), apply warm, moist heat to the affected part to reduce swelling and provide comfort. Heat applications should not exceed 20 to 30 minutes. Allow a "cool-down" time between applications. Encourage the patient to use the limb if the joint is protected by a cast, brace, splint, or taping. Joint movement maintains nutrition to cartilage, helps prevent contracture (stiffening) of tendons and ligaments, and muscle contraction improves circulation to help resolve bruising and swelling.

Emphasize the importance of strength and conditioning exercises to prevent reinjury. The physical therapist may help with pain relief through ultrasound or other interventions and teach the patient exercises to improve flexibility and strength.

TABLE 67.3  EMERGENCY MANAGEMENT

Acute Soft Tissue Injury