11.14 Contusions (Bruises)
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agk's Library of Common Simple Emergencies

Presentation
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The patient has fallen, has been thrown against 
an object or has been struck at a site where now 
there is point tenderness, swelling, ecchymosis, 
hematoma, or pain with use. On physical 
examination, there is no loss of function of 
muscles and tendons (beyond mild splinting 
because of pain), no instability of bones and 
ligaments, and no crepitus or tenderness produced 
by remote stress (such as weight-bearing on the 
leg or manual flexing of a rib).

What to do:
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- Take a thorough history to ascertain the 
    mechanism of injury and perform a complete 
    examination to document structural integrity 
    and intact function.
- Reserve x rays for possible foreign bodies and 
    bony injury. Fractures are uncommon after a 
    direct blow, but are suggested by pain with 
    remote percussion or stressing of bone or an 
    underlying deformity or crepitus. The yield 
    is very low when x rays are ordered on the 
    basis of pain and swelling alone.
- Explain to the patient that swelling will peak 
    in 1 day, then resolve gradually, and that 
    swelling, stiffness and pain may be reduced 
    by good treatment during the first 1-2 days.
-   Prescribe:
    - resting the affected part,
    - immobilization (the ultimate in rest, best 
        achieved with a splint),
    - elevation of the affected part (ideally, 
        above the level of the heart), and
    - cold (usually an ice bag, wrapped in a 
        towel, applied to the injury for 10-20 
        minutes per hour for the first 24 hours).
- Explain to the patient the late migration and 
    color change of ecchymoses, so that green or 
    purple discoloration appearing farther down 
    the limb a week after the injury does not 
    frighten him into thinking he has another 
    injury.
- Large intramuscular hematomas (especially of 
    the anterior thigh) may require drainage or 
    orthopedic consultation.
- Arrange for re-evaluation and followup if there 
    is any continued or increasing discomfort.

What not to do:
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- Do not apply an elastic bandage to the middle 
    of a limb, where it may act as a tourniquet. 
    Include all of the distal limb in the 
    wrapping if a compression dressing is 
    necessary.
- Do not confuse patients with instructions for 
    application of heat and exercises to prevent 
    stiffness and atrophy. Concentrate on the 
    here-and-now therapy of the acute injury; 
    namely, rest, immobilization, elevation, and 
    cold: all designed to decrease acute edema. 
    Leave other instructions to followup and . 
    physical therapy consultants. Patients who 
    confuse today's correct therapy with next 
    week's can complicate their problem.
- Do not take for granted that all of your 
    patients understand rest, immobilization, 
    elevation, and cold. Walking on a fresh foot 
    injury or soaking it for long periods in ice 
    water or Epsom salts are not usually 
    therapeutic.

Discussion
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The acute therapy of contusions concentrates upon 
reduction of the acute edema, and all other 
components of treatment are postponed for 3-4 
days, until the inflammation and edema are 
reduced. Patients need to know this time course, 
and must understand that the more the swelling 
can be reduced, the sooner injuries can heal, 
function return and pain decrease. Edema of hands 
and feet is especially slow to resolve, because 
these structures usually hang in a dependent 
position, and require much modification of 
activity to rest.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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