Management of acute injury

Effective management of injuries from the outset will substantially reduce the pain and disability involved.

Initial caution

Before going ahead with management it is important to exclude serious diagnoses which need medical attention. Symptoms to be wary of include (not exclusively):
•Severe pain which does not ease with time
•Sudden and severe swelling
•Deformity/misalignment of the injured part
•Severe loss of the ability to use the par
•Strong guarding of the part, or unusual movement
•Grating or crunching at the site of injury

If you have any worries about the injury, consult a medical practitioner or a physical therapist. Once all serious diagnoses have been excluded, you can go on to treating your injury itself

The Five Principles of injury management

Remember PRICE
1.Protection – reducing stresses on the injured part until it is able to cope with them.
2.Rest – again to reduce stresses to allow healing and avoid reinjury.
3.Ice – to reduce the swelling and metabolic activity of the injured area.
4.Compression – to keep pressure on the swelling and stop it getting too great.
5.Elevation – to keep the swelling down and prevent pressure in the damaged tissues.

Protection

The injury should be protected in its early stages, which means up to day three initially. The length of time protection is needed varies with the severity and studies point to a moderate (second degree) injury requiring three to five days protection. Shorter or longer protection periods may be needed for first (mild) or third (severe) degree injuries.

The type of protection depends on the site and nature of injury and may vary from using crutches to reduce weightbearing to fitting braces or splints. It is important not to immobilize any structures which do not need to be kept still and any protective device has to allow for the possibility of increasing swelling.

There is some evidence from animal studies to support protection during the first three to five days after injury, but beyond that little scientific guidance is available to support one or other treatment method.

Rest

Immediately after injury, the injured part should be rested, and stress on the injured body tissues avoided in the inflammatory phase because the tissues have greatly reduced tolerances to force at this stage.

One to five days of rest appears to be the best period but this does depend on the severity of the damage. Mild injuries could need just a day, moderate ones from three to five days, and severe ones a week or more.

When the area is mobilised after the rest period it is useful to avoid significant stress on the damaged area, and if it is a ligament or joint, isometric muscle work can be used.

The judgement is to apply the correct loads for the damaged structure at the correct time. Evidence shows that correct loads at the right time can promote healing of fibrous tissue, and that excessive force can increase scarring and slow down muscle recovery.

A suitable period of immobilization, eg 3-5 days for a moderate injury, increases the formation of the scarring tissue, then mobilization at the right time encourages muscle to grow into the scar and makes the new tissue line up with the original orientation.

Ice

Use ice immediately after injury, with crushed or chipped ice in a damp towel the most effective method. To avoid “ice burn” (cold related skin damage) wet a towel thoroughly then wring it out to use it.

20-30 minutes icing seems to be the most effective timing, and this can be repeated two hourly, but there is no scientific evidence for this. To avoid skin and nerve damage, it is recommended that icing is not extended beyond thirty minutes. Longer periods such as thirty minutes may be needed over areas with more than 2cm of fat under the skin, as shorter times may provide no tissue cooling.

Immediately after ice application the speed of nerve conduction, feeling in the area and the flexibility of tissues have all been reduced. This makes it unwise to go back to activity until these effects have worn off.

Areas at greater risk of side effects from ice are body parts with little fat (eg on very thin people) and areas around nerves when they are close to the surface of the body. Icing time should be reduced to 10 minutes in these cases, and the situation assessed regularly.

Ice should be avoided in people who suffer from cold induced problems such as urticaria, joint pain, high blood pressure, Raynaud’s syndrome, peripheral vascular disease and sickle cell anaemia. If the area to be treated has had past nerve damage or present suspected damage then icing time should be reduced and the skin checked every 5 minutes to ensure all is well

Compression

Compression aims to reduce the level of swelling or bleeding, and force the tissue fluid leaking out into the injured area back into the blood and lymph vessels.

It is important to start compression further away from the body and work closer, and the pressure of compression should not be higher closer to the body, or it will act like a tourniquet.

Compression should be applied for some distance above and below the injury, and be able to cope with either increasing pressure as the injury develops or decreasing pressure as it resolves. It may also be important to pad any bony prominences or superficially prominent tissues such as tendons.

Apply compression as soon as possible after injury, monitor the circulation in the limbs to check compression is not excessive (eg coldness, numbness, pain, paleness in the limb beyond the compression), and reapply the compression if there are any problems or at 24 hours. It may be unwise to keep compression on overnight without supervision.

Compression can be kept up for up to 72 hours as appropriate and elastic bandages and tubigrip appear to be most effective.

Elevation

Gravity doesn’t just make the planets run in their orbits, or apples fall! It also pulls the fluids in our bodies down towards the lowest point. The areas which are most dependent (ie hanging down) are the arms and legs, and it is here that swelling can accumulate.

It is logical to assume that elevation will reduce the circulation in the limb and therefore reduce any developing swelling. There is little good evidence to support this but it does still seem to hold up in practice.

In the first 72 hours after the injury the injured part should be raised above heart level, and be well supported by a pillow or other item. The sooner the part is elevated after the injury, the better. Avoid hanging the affected part down immediately after it has been up for a while as this can lead to increased swelling.