Sunday, February 10, 2013

Lesson Nine: Ortho

Lesson Nine: Sprains, Fractures, and RICE

You or someone else has suffered the dreaded FDGB. (Fall Down, Go Boom!)
There was a "pop" sound. It really hurts.
Did you sprain something, or break a bone, and what should you do?

No, not Uncle Ben's, or Mahatma, or any other starchy food product.
This is an acronym. We'll get to it in a minute.

Let's work backwards. From the ER, I tell patients the following when they come in with a possible sprain/fracture:

If you sprained (Generic Body Part), we're going to X-ray it, wrap it, tell you not to use it, and give you prescriptions for pain medication.

If you fractured (Generic Body Part), we're going to X-ray it, wrap it, tell you not to use it, and give you prescriptions for pain medication.
Then splint it, and refer you to an orthopedic specialist for a cast in 2-3 days, after the swelling is minimal.

 What I hope they (and you) learn from this is that in almost all cases in the short term, whether you sprained something or fractured it doesn't realy matter. And the treatment is nearly identical. Before, and after. Now, back to RICE.

R: Rest

Don't use it. Courtesy of the Groucho Marx School of Medicine, "If it hurts to go like that, don't go like that."

Immobilize it. You can make splints out of scrap cardboard, rolled up magazines, bedsheets, duct tape, or darn near anything. (I'm going to cover improvisation in the near future.) And, if you have them, you can use purpose-designed splinting equipment. The key to remember is that you're trying to prevent movement of the joint above and the joint below the injury. The point is, make it so the part doesn't move much, if it all, and the patient shouldn't be using it. Period.

I: Ice.

See Lesson Eight, above. Whatever you smacked, ice it. Go big. Unless hypothermia is a problem, cover that injury site in ice, and keep it on for 20 minutes. You'll stop a HUGE amount of swelling today, which means you've stopped pain for the whole week. Remove the ice for 1 to 1.5 hours, then re-apply ice. Ice, not heat. And you can continue cold therapy for 3-4 days. At that point, you've probably maxxed out on stopping swelling. (Down the road, if it's a sprain, at 4 days or more you can switch to heat therapy, on the theory that it will help increase circulation and thus speed healing. It also relaxes muscles and feels good.)

C: Compression

Short of making it a tourniquet, preventing injured parts from swelling can also be aided by something tight around it. In the hospital, we may do a padded splint, a neoprene sleeve, or an ACE bandage wrap. Having a couple of the last-mentioned in your kit is probably a great idea. Put the ACE wrap on from the farthest point of injury on an extremity, and roll it on going toward the heart (e.g. from the wrist toward the elbow, or from the toes towards the calf). No ACE wraps for neck injuries, please. And don't wrap torso/rib injuries. We want our patients to breathe, okay?

Check after you apply it. If things are suddenly numb/tingly after it's applied, or if you squeeze a fingernail/toenail lightly, and it stays white, or returns to normal pinkness s-l-o-w-l-y (like more than 2 seconds) you've wrapped too tight. Remove, and try again. Re-check frequently until your patient gets to medical care to make sure your wrap hasn't become a tourniquet due to swelling. And remove anything else like bracelets or rings on fingers/toes that might do the same thing. Do it early, before you need to cut the jewelry off. If it's already too late, cut the jewelry off. Jewelers can fix rings much cheaper than hand surgeons can fix fingers.

 E: Elevation

Elevate the part. It doesn't have to be strung up like those old hospital beds in Three Stooges films. The level of your heart will do. For a lower extremity, any elevation above the floor will be an improvement. Sitting sideways on a car seat or couch is tons better (and, you'll notice, less painful) than putting it down on the floor. Why?

Because gravity works. The fluids in your body move to the dependent (that means lower) parts. Fluids mean swelling. Swelling means pain. Raise things up, they don't swell, they don't throb, and you're happier. That's why you don't walk with an injured leg other than necessities (like bathroom trips), because even if you're using crutches and not walking on that leg, it's hanging down low, and swelling, and throbbing, and it's no fun. Stay off it and get it elevated.

When you go to your doctor, or the ER, you'll get similar instructions. Along with prescriptions for (usually) narcotic pain relievers, and an NSAID - non-steroidal anti-inflammatory drugs.

The typical NSAIDs are aspirin, ibuprofen, and naproxen.

The Rx won't be for aspirin, because it "thins your blood" (technically, decreases clotting) which makes you more likely to bleed. If tissue was bruised, you've damaged some small blood vessels, so aspirin would only make that leakage worse, and increase swelling and pain.

The Rx will probably be for ibuprofen (think Motrin/Advil/any generic brand). It doesn't affect clotting, unlike aspirin. But it does do two things we really like: it relieves pain (just like aspirin or Tylenol would); and it decreases swelling (UNlike aspirin or Tylenol). This is what makes ibuprofen better in most cases, and why doctors recommend you take it to prevent swelling, even if you're not in pain.

{Obligatory advisory:Read and follow all label directions. Consult your doctor before taking any medication. Ibuprofen may be contraindicated in persons with kidney or liver diseases. Void where prohibited by law. Post no bills. Etc. Etc.

Naproxen (e.g. Aleve) may be selected because you're allergic to ibuprofen, have one of the contra-indicating conditions, or because you've found it works better and told the doctor that before he wrote the Rx. It acts like ibuprofen, except in ways too technical to worry about here. The important thing is it doesn't have the blood-thinning effects of aspirin either.

Sprain or fracture, remember RICE, before and after you get your patient to the ER. It's free, and it works.

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