UNIT 3: CONTUSIONS/SPRAINS
Key Unit competence
Take appropriate decision on contusions and sprains
Introductory activity 3.0
The below images (A,B) illustrate different normal and abnormal structures of ankles. Observe them and respond to the questions attached.
1. Describe the abnormal structures of ankle observed
2. What could be the causes of such abnormalities?
3. What are the manifestations of such abnormalities in the human body?
4. How can health personnel identify or notice these abnormalities?
5. How can these abnormalities be corrected
3.1. Contusions/ Sprains
Learning Activity 3.1
A 35-year-old woman attends the clinic after she was mopping the house causing her to slip on some water. She fell, rolling her right ankle to the side. She also used her right hand to support her during a fall and she is complaining pain at the same hand. She was able to get up and weight bear through her injured ankle, limping to the nearest hospital.
On inspection, her left ankle was pretty sore with some noticeable swelling of her ankle. She was not able to walk properly. On her right hand, a bruise and swelling were also observed.
Questions related to the case study
1. What is a sprained ankle/what is contusion?
2. What was done to reduce the swelling?
3. How long will it take to recover?
4. When can she resume her sport?
3.1.1 Definition of terms
A sprain is a stretching or tearing of ligaments, the tough bands of fibrous tissue that connect two bones together in the joints. The most common location for a sprain is in the ankle.
A contusion is an injury that causes bleeding and tissue damage underneath the skin, usually without breaking the skin. Any injury that puts pressure on an area repetitively can cause a contusion.
3.1.2 Causes and risk factors of contusions/sprains
A sprain occurs when there is an overextension or tear of a ligament while severely stressing a joint. Sprains often occur in the following circumstances:
– Ankle: Walking or exercising on an uneven surface, landing awkwardly from a jump Knee: Pivoting during an athletic activity
– Wrist: Landing on an outstretched hand during a fall
– Thumb: Skiing injury or overextension when playing racquet sports, such as tennis
Children have areas of softer tissue, called growth plates, near the ends of their bones. The ligaments around a joint are often stronger than these growth plates, so children are more likely to experience a fracture than a sprain.
Factors contributing to sprains include:
– Environmental conditions. Slippery or uneven surfaces can make people more prone to injury.
– Fatigue. Tired muscles are less likely to provide good support for the joints. When an individual is tired, she/he is also more likely to succumb to forces that could stress a joint.
– Poor equipment. Ill-fitting or poorly maintained footwear or other sporting equipment can contribute to the risk of a sprain.
Contusions also called bruise are black-and-blue spots. This happens when small blood vessels get torn and leak blood under the skin. But bones, muscles, and organs can also get bruised. This may damage deep tissues but not cause a bruise that can be seen.
a) Subcutaneous contusion
A subcutaneous contusion (fig. 3.1 A) is the bruise that most people are familiar with. A subcutaneous contusion is a bruise just beneath the skin. Almost everyone experiences a subcutaneous contusion at some point. Just as a cut bleeds from tiny blood vessels, injuries to tiny blood vessels under the skin cause most subcutaneous contusions. Areas that a person may land on or use to support themselves during a fall, such as the hands and knees, are particularly vulnerable.
Very rarely, a large bruise causes massive bleeding, from a vein or artery that is difficult to stop. This can be life-threatening without treatment.
b) Muscle contusion
The muscles are full of blood vessels that supply them with blood and oxygen. A bruise to a muscle is deeper than a subcutaneous contusion, and it can be very painful. A person with a muscle contusion may think that they have a sprain, strain, or broken bone.
c) Bone contusion
A bone contusion can feel similar to a break or fracture, and it may make it difficult to move the area of the injury.
d) Eye contusion
An eye contusion is a bruise on or around the eye. Contusions on the eyelid can be painful and may look swollen. However, they are rarely serious. A person may also bruise the cornea, which is the tissue inside the eye. This can be more serious, especially without treatment or if there are other eye injuries present.
e) Cartilage contusion
Cartilage is flexible but thick tissue that is harder than muscle but softer than bone. The outside of the ears and the tip of the nose both contain cartilage.
f) Organ contusion
Internal organs such as the kidneys, lungs and heart can develop bruises after a forceful blow or fall. Organ contusions damage the blood vessels and other soft tissue in organs. These injuries are dangerous, and they can be life-threatening. This is because they may interfere with the functioning of the organ. People with organ contusions may require hospitalization. For example, a person with a pulmonary contusion, or a bruise on the lungs, may need to use an artificial ventilator.
3.1.3 Clinical manifestations of contusions/sprains
Signs and symptoms of sprains will vary, depending on the severity of the injury, and may include; pain, swelling, bruising, limited ability to move the affected joint and hearing or feeling a “pop” in the joint at the time of injury. Depending on the junction or ligament affected, a turn in or out of the joint maybe observed.
As it was mentioned early, the most common location for a sprain is in the ankle, usually involving the foot and ankle turning inwards (inversion) and damaging at least one of the ligaments on the outside of the ankle. It is possible to twist the ankle outwards (eversion) but this is far less common (fig3.2).
There are two different basic classifications of ankle sprains: Anatomic (the level severity of damage to tissues in the ankle) and functional (the level an injury affects a patient’s ability to walk or put weight on the ankle).
Anatomic Classifications
Grade I ankle sprain – lateral ligaments are strained (overstretched)
– Grade II ankle sprain – partial tearing of one or several of these ligaments
– Grade III ankle sprain – complete rupture (tear) one or more of the lateral ligaments
Functional Classifications
– Grade I injury – the patient is able to fully weight bear and walk
– Grade II injury – the patient walks with a noticeable limp
– Grade III – the patient is unable to walk
For most contusions, the main symptom is pain. The pain can be either mild or severe. Larger, deeper contusions, such as those affecting the bone or muscles, are typically more painful. If there is pain following a fall or blow, there may be a contusion. Some common symptoms of a contusion include:
– Red, blue, or black swelling near the injured area
– Throbbing or aching
– Difficulty moving the area
Contusions to organs can affect their ability to function. Following a hard blow to the stomach, back, or chest, a person should seek immediate medical treatment for pain, swelling, weakness, or any signs of illness. These could be signs of an organ contusion.
Difficulty breathing or changes in heart rate could be signs of a lung or heart contusion. These are medical emergencies that require immediate treatment.
3.1.4 Diagnostic measures of contusion/sprains
A physical exam is performed; touch the skin around the injury to check for points of tenderness. Ask the patient to move his/her foot to check the range of motion and to understand what positions cause discomfort or pain.
If the injury is severe, one or more of the following imaging scans are done to rule out a broken bone or to evaluate in more detail the extent of ligament damage:
– X-ray; during an X-ray, this test is good for ruling out bone fractures.
– Magnetic resonance imaging (MRI) good for soft internal structures of the ankle, including ligaments.
– CT scan; can reveal more detail about the bones of the joint.
– Ultrasound; may help to judge the condition of a ligament or tendon when the foot is in different positions.
3.1.5 Therapeutic Measures of contusions/sprains
Most contusions of bones, muscles, skin, and cartilage will not need medical treatment. Instead, using the RICE method at home can help with pain and swelling, as well as speed up recovery. Organ contusions may require more intensive treatment, surgery to repair an injury or stop the bleeding.
Treatment for a sprains depends on the severity of the injury. The treatment goals are to reduce pain and swelling, promote healing of the ligament, and restore function of the joint.
– Self-care: For self-care of an ankle sprain, R.I.C.E. approach is used for the first two or three days:
– Rest: Avoid activities that cause pain, swelling or discomfort.
– Ice: Use an ice pack or ice slush bath immediately for 15 to 20 minutes and repeat every two to three hours while. If a patient has vascular disease, diabetes or decreased sensation, she/he has to talk with the doctor before applying ice.
– Compression: To help stop swelling, compress the ankle with an elastic bandage until the swelling stops. Don’t hinder circulation by wrapping too tightly. Begin wrapping at the end farthest from your heart.
– Elevation: To reduce swelling, it is recommended to elevate the joint above the level of the heart, especially at night. Gravity helps reduce swelling by draining excess fluid.
– Medications: In most cases, over-the-counter pain relievers
— such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) or acetaminophen (Tylenol, others)
— are enough to manage the pain of a sprained joint.
– Devices: Because walking or maintaining a normal position with a sprained joint might be painful, using crutches until the pain subsides is recommended. Depending on the severity of the sprain, an elastic bandage, sports tape or joint support brace to stabilize the joint are recommender. In the case of a severe sprain, a cast or walking boot may be necessary to immobilize the ankle or any other joint while it heals.
– Physiotherapy: Once the swelling and pain is lessened enough to resume movement, a series of exercises to restore the range of motion, strength, flexibility and stability may be recommended.
– Surgery: In rare cases, surgery is performed when the injury doesn’t heal or the joint remains unstable after a long period of physical therapy and rehabilitative exercise. Surgery may be performed to:
– Repair a ligament that won’t heal
– Reconstruct a ligament with tissue from a nearby ligament or tendon
3.1.6 Complications of contusions/sprains
Skin contusions most of the time do not have complications but organ contusions may have complications. For example, a person with a pulmonary contusion, or a bruise on the lungs, may need to use an artificial ventilator.
Sprains complications are:
– Chronic pain
– Chronic joint instability
– Arthritis in the joint
3.1.7 Associate nurse decision making
The associate nurse will help the patient to apply RICE methods to treat contusions/ sprains and teach the patients how to prevent the contusions/sprains.
Self-assessment activity 3.1
1. What is the difference between a sprain, strain and contusion?
2. Identify the common factors associated with sprain
3. What are the signs and symptoms of a contusions/sprain?
4. Explain the types of contusions
3.2 End unit assessment
End of unit assessment
1. If you have a sprain, it means you’ve injured a ligament.
a) True
b) False
c) The most common site of a sprain is the wrist
d) True
e) False
2. A typical sprain occurs when you misstep and land on the side of your foot.
a) True
b) False
c) Explain the pathophysiology of contusions?
d) What is the difference between inversion and eversion sprain of ankle?
e) Identify the diagnostic measures of sprains
3. The ICE method is commonly used for self-care of sprains and contusions. Explain this method.
4. Based on function classification of sprains of ankle, describes different stages of sprains.