Treatment of serious injuries
In the emergency department, doctors check for injuries that require immediate treatment. If the skin is torn, the wound is covered with a sterile dressing, and the injured person is given a vaccine to prevent tetanus (see Diphtheria-Tetanus-Pertussis Vaccine) and antibiotics to prevent infection. Also, the wound is cleaned, usually after a local anesthetic is used to numb the area.
To make sure the injured part is not deprived of blood, doctors surgically repair damaged arteries unless the arteries are small and blood flow is not affected.
Severed nerves are also repaired surgically, but this surgery can be delayed until several days after the injury if necessary. If nerves are bruised or damaged, they may heal on their own.
Pain relief
Pain is treated, typically with opioid pain relievers and/or acetaminophen. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs—see NonopioidAnalgesics :Nonsteroidal Anti-Inflammatory Drugs) are not usually recommended because they are usually no more effective than acetaminophen and, in some people, may worsen bleeding.
PRICE
PRICE refers to the combination of protection, rest, ice, compression (pressure), and elevation. This treatment is used to treat injured muscles, ligaments, and tendons.
Protectionhelps prevent further injury that could worsen the original one.Typically, a splint or other device is applied.
Rest prevents further injury and may speed healing. People should limit their activity and avoid putting weight on and/or using the injured body part. For example, they should use crutches and not participate in contact sports.
Ice and compression minimize swelling and pain. Ice is enclosed in a plastic bag, towel, or cloth and applied for 15 to 20 minutes at a time, as often as possible during the first 24 to 48 hours. Usually, compression is applied to the injury with an elastic bandage.
Elevating the injured limb helps drain fluid away from the injury and thus reduce swelling. The injured limb is elevated above heart level for the first 2 days.
After 48 hours, people can periodically apply heat (for example, with a heating pad) for 15 to 20 minutes at a time. Heat may relieve pain. However, whether heat or ice is best is unclear, and what works best may vary from one person to another.
Reduction
Often, certain injured parts must be moved back into their normal position (realigned, or reduced). Forexample, reductionisusuallynecessaryif
· Pieces of a broken bone have become separated (displaced).
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· Pieces of a broken bone are out of alignment.
· A jointisdislocated.
Certain fractures in children do not need to be realigned because the bone, which is still growing, can correct itself.
If possible, reduction is done without surgery (called closed reduction), by manipulation—for example, by pulling and/or turning a limb. After reduction is done, doctors usually take x-rays to determine whether the injured parts are in their normal position.
Some injuries must be realigned surgically (called open reduction—see Surgery).
Because reduction is usually painful, people are usually given pain relievers, sedatives, and/or an anesthetic (see Surgery : Anesthesia) before the procedure. The types of drugs that are used depend on how severe the injury is and how reduction is to be done:
· Closed reduction of minor fractures (such as those of the fingers or toes): A local anesthetic, such as lidocaine, injected near the injured part, may be all that is needed.
· Closed reduction of major fractures (such as those of the arm, shoulder, or lower leg): People may be given a sedative and pain relievers by vein. The sedative makes them drowsy but not unconscious. They may also be given a local anesthetic by injection. For example, if people have a shoulder dislocation, lidocaine may be injected into the shoulder joint.
· Open reduction: People are given a general anesthetic by injection or through a face mask, making them unconscious. Thisprocedureisdoneinanoperatingroom.
Immobilization
After being realigned, the injury must be kept from moving (be immobilized).
Casts, splints, or slings are usually used after closed reduction of a fracture or dislocation.
Hardware devices, such as pins, screws, rods, and plates, are often used during open reduction of a fracture. This procedure is called open reduction and internal fixation (ORIF—see Surgery).
Immobilization reduces pain and helps with healing by preventing further injury to surrounding tissues. If a leg or an arm bone is fractured, immobilization may help prevent fat embolism. Immobilization is helpful for most moderate or severe injuries. Joints on both sides of the injury are immobilized.
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If immobilization lasts too long (for example, for more than a few weeks in young adults), the joint may become stiff, sometimes permanently, and muscles may shorten (causing contractures) or shrink (waste away, or atrophy). Blood clots may develop. Such problems can develop quickly, and contractures can become permanent, usually in older people. Consequently, doctors encourage movement as soon as the fracture heals. They also tend to use treatments that enable older people to walk as soon as possible (such as surgical repair of a hip fracture), rather than ones that require them to be immobilized for a long time (such as bed rest or a cast).
Whether immobilization is required and which technique is used depend on the type of injury.
Most fractures are immobilized with a cast, splint, or sling until they heal. Without immobilization, the broken ends are likely to move, healing is slower, and the bones may not grow back together. If the broken bones have been separated (displaced), they must be realigned (reduced) before being immobilized.
If a partial tear in a tendon is suspected or if the diagnosis is uncertain, doctors may apply a splint to immobilize the injured part so that the tendon can heal. Some severe tendon tears are immobilized for days or weeks, sometimes with a cast.
Mild sprains are immobilized briefly if at all. Moving the injured part as soon as possible is usually the best treatment. Moderate sprains are often immobilized with a sling or splint for a few days. Some severe sprains are immobilized for days or weeks, sometimes with a cast. However, some severe sprains must be surgically repaired and are not always immobilized.
Some dislocated joints require only a sling or splint. It is applied after the joint is returned to its normal position. Joints are immobilized to prevent them from moving and possibly causing further injury.
Casts are usually used for injuries that must be kept immobilized for weeks.
To apply a cast, doctors wrap the injured part in cloth, then apply a layer of soft cottony material to protect the skin from pressure and rubbing. Over this padding, doctors wrap dampened plaster-filled cotton bandages or fiberglass strips, which harden when they dry. Plaster is often used to immobilize broken bones that have been separated because it molds well and is less likely to rub against the body. Fiberglass casts are stronger, lighter, and longer-lasting. After a week or so, the swelling goes down. Then, the plaster cast can sometimes be replaced with a fiberglass cast to fit the limb more snugly.
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People who require a cast are given special instructions for its care. If a cast is not correctly cared for, problems can develop. For example, if the cast becomes wet, the protective padding under the cast may become wet, and drying it completely may be impossible. As a result, the skin can soften and break down, and sores may form. Also, if a plaster cast gets wet, it can fall apart and thus no longer protect and immobilize the injured area. People are instructed to keep the cast elevated as much as possible at or above heart level, especially for the first 24 to 48 hours. They should also regularly flex and extend their fingers or wiggle their toes. These strategies help blood drain from the injured limb and thus prevent swelling.
Pain, pressure, or numbness that remains constant or worsens over time must be reported to a doctor immediately. These symptoms may be due to a developing pressure sore or compartment syndrome (see Compartment Syndrome.). In such cases, doctors may have to remove the cast and apply another one.
TakingCareof a Cast
| · When bathing, enclose the cast in a plastic bag and carefully seal the top with rubber bands or tape or use a waterproof cover designed to cover a cast. Such covers are commercially available, convenient to use, and more reliable. If a cast becomes wet, the padding under the cast may retain moisture. A hair dryer can remove some dampness. Otherwise, the cast must be changed to prevent skin from breaking down. · Never put an object inside the cast (for example, to scratch an itch). · Check the skin around the cast every day, and report any red or sore area to a doctor. · Check the edges of the cast everyday, and if they feel rough, place soft adhesive tape, tissues, cloth, or another soft material to pad them and keep them from injuring the skin. · When resting, position the cast carefully, possibly using a small pillow or pad, to prevent the cast's edge from pinching or digging into the skin. · Elevate the cast regularly, as directed by the doctor, to control swelling. · Contact a doctor immediately if the cast causes persistent pain or feels excessively tight. These symptoms may result from pressure sores or swelling, which may require immediate removal of the cast. · Contact a doctor if the cast gives off an odor or if a fever develops. Thesesymptomsmayindicateaninfection. · Contact a doctor if the cast causes worsening pain or new numbness or weakness. Thesesymptomsmayindicatecompartmentsyndrome. |
A splint can be used to immobilize some fractures, sprains, and other injuries, particularly if they need to be kept immobile for only a few days or less. Splints allow people to apply ice and to move more than a cast does.
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A splint is a long, narrow slab of plaster, fiberglass, or aluminum applied with elastic wrap or tape. Because the slab does not completely encircle the limb, there is room for some expansion due to swelling. Thus, a splint does not increase the risk of developing compartment syndrome. Some injuries that eventually require a cast are first immobilized with a splint until most of the swelling resolves. For finger fractures, aluminum splints lined with foam are commonly used.
A sling by itself can provide sufficient support for many shoulder and elbow fractures. The weight of the arm pulling downward helps keep many shoulder fractures aligned. Slings can be useful when complete immobilization has undesirable effects. For example, if a shoulder is completely immobilized, the tissues around the joint may become stiff, sometimes within days, preventing the shoulder from moving (called frozen shoulder). Slings limit movement of the shoulder and elbow but allow movement of the hand.
A swathe, which is 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.
Bed rest, which is occasionally required for fractures (such as some fractures of the spine or pelvis), can cause problems (see Problems Due to Bed Rest), including blood clots, and a decrease in general physical fitness (deconditioning).
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