Chapter 6. Immediate Care of Acute Orthopedic Injuries

1. Chapter 6. Immediate Care of Acute Orthopedic Injuries

2. RICES • The prescription for immediate care • RICES • Rest • Ice • Compression • Elevation • Stabilization

3. Immediate 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.

4. What Is Immediate Care? • Care given immediately after an acute orthopedic injury • Subset of acute orthopedic injury care

5. Acute Orthopedic Injury Care Typically three stages • Acute (0–4 days) • Subacute (5–14 days) • Postacute (>14 days)

6. 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

7. Acute Orthopedic Injury Care (cont.) New three stages • Acute (0–4 days) • Emergency care (e.g., CPR, if needed) • Immediate care (0–12 h) • Transition care (12 h to 4 days) • Subacute (5–14 days) • Postacute (>14 days)

8. Why RICES? • To limit (decrease): • Total injury • Swelling • Pain • Further injury • Muscle spasm • Inflammation? NO

9. RICES Theory • Rest • Ice • Compression • Elevation • Stabilization

10. Rest: Why? Limits injury aggravation • Should be total during immediate care • Transition to “relative” rest • Different from, but related to, stabilization

11. 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.

12. Ice/Cold: Why? (cont.) • Two theories • Circulatory or decreased blood flow theory • Decreased secondary injury theory

13. Decreased 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.

14. 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. Decreased Secondary Injury Theory

15. 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

16. Decreased Secondary Injury Theory (cont.)

17. Decreased Secondary Injury Theory (cont.)

18. Metabolism and Cooling • Direct relationship • More cooling means greater decrease in metabolism

19. Metabolism and Cooling (cont.) • Heat increases metabolism. • Causes more secondary injury

20. Cryotherapy 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

21. Controls edema beyond normal volume (i.e., after tissue spaces are filled) Apply constantly until swelling is over. Compression: Why?

22. Compression enhances cooling. Compression: Why? (cont.)

23. Elevation: Why? • Decreases capillary hydrostatic pressure

24. 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

25. Stabilization: Why? (cont.) Allows muscles to relax, thus • Decreases pain–spasm–pain cycle • Numerous braces and splints for stabilization

26. RICES Theory: Revisited • Rest • Ice • Compression • Elevation • Stabilization

27. What Is the Goal of Cold? • Decrease tissue metabolism! • More cooling means greater decrease in metabolism.

28. Does It Matter How You Apply Cold? • Yes • Great differences in tissue cooling

29. Cryotherapy Physics and Physiology • Cold does not exist; it is not a physical substance. • Cold is absence of heat.

30. Physiology 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

31. Rate 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

32. Heat Storage Capacity • Specific heat • Latent heat of fusion

33. 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

34. 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

35. 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

36. Heat Storage Capacity (cont.) Crushed ice pack better than gel pack

37. Temperature Changes Resulting from Cold Pack Application • Surface temperature • Repeated applications • Time ratio • Activity between applications (shower) • Compression wrap over cold pack

38. Temperature Changes Resulting from Cold Pack Application (cont.)

39. Temperature Changes Resulting from Cold Pack Application (cont.) • Tissue temperature • Depends on depth and type of tissue • Delayed response • Continues to decrease after application

40. Temperature Changes Resulting from Cold Pack Application (cont.)

41. Temperature Changes Resulting from Cold Pack Application (cont.) • Tissue temperature • Amount of adipose tissue • Rewarming takes hours

42. Temperature Changes Resulting from Cold Pack Application (cont.)

43. 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

44. 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)

45. Cryotherapy: Application Principles • Tissue cooling depends on • Cold modality used • How modality is applied • Many protocols suggest • Length • Frequency • Duration

46. 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 Factors That Affect Tissue Cooling

47. 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) Factors That Affect Tissue Cooling (cont.)

48. Types of Cold Packs Four general types: • Crushed ice • Gel (Chattanooga, Cramer) • Artificial ice • Water in vinyl (Dura*Kold) • Chemical • Double bags, crushable • Powder types

49. 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) Types of Cold Packs (cont.)

50. 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 Types of Cold Packs (cont.)