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Contusions: Treatment & Medication
Updated: Apr 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
In the acute phase following a muscle contusion, hematoma maturation, inflammation, necrosis of damaged myofibrils, and phagocytosis of the necrotic debris are main features. The goal of therapy is to minimize hemorrhage and inflammation and control pain. Limb immobilization with rest, ice, compression, and elevation (RICE) should be performed for the first 24 hours in patients with minor contusions and for 48 hours in patients with moderate or severe contusions.
The general recommendation is to avoid heat during the first 24-48 hours to avoid increasing the extent of hemorrhage and edema. Once the lesion has stabilized, heat may help break up the mass of blood and tissue; however, in the literature, this has been shown to be of limited benefit.
The use of crutches should be emphasized for patients with thigh contusions, as weight bearing following the thigh contusion injury may be extremely painful and may extend the damage. The knee joint should be flexed to pain tolerance in conjunction with the compression dressing. Compression gently increases tension, limiting the extent of the intramuscular hematoma. In addition, the position of flexion stretches the muscle, which increases tension and also facilitates drainage of the edematous fluid from the region.
The contusion generally stabilizes by 24-48 hours, and subsequent evaluation should dictate further treatment and prognosis. Reinjury is a significant factor in prolonging disability, and patients must be instructed to avoid retraumatizing the muscle.
Occupational Therapy
In the first phase of rehabilitation of a contusion, an occupational therapist may become involved by educating the patient about proper crutch use and tailoring the patient's activities of daily living (ADL) to the immobilized limb.
Medical Issues/Complications
The index of suspicion for compartment syndrome must be high until the hemorrhage, swelling, and pain have subsided (see Miscellaneous, Medical/Legal Pitfalls).
Surgical Intervention
Surgical intervention should not be necessary in cases of contusions, unless the diagnosis of compartment syndrome is considered and confirmed.
Consultations
If the diagnosis is in question or if myositis ossificans is confirmed by radiographs, orthopedic consultation can be obtained. Compartment syndrome is a surgical emergency, and an immediate consultation should be made if the diagnosis is confirmed.
Other Treatment
Multiple therapies that have become commonplace in the treatment of contusions exist. However, most therapies have not been proven to provide any benefit, and some may be damaging to the healing tissue.
In a given situation, an injection of epinephrine (with lidocaine) may be considered in the acute phase of a contusion injury, along with ice and compression to help limit bleeding.
- Therapeutic ultrasound is a commonly used physical therapy modality that has been claimed to promote tissue repair by enhancing cell proliferation and protein synthesis during the healing of skin wounds, tendon injuries, and fractures. The theory is that of a micromassage effect. However, ultrasound can enhance both myogenic precursor cell and fibroblast proliferation. Prolonging the proliferation phase of fibroblasts during muscle regeneration can add to the amount of permanent scar-tissue production, which could outweigh the possible positive effects of ultrasound on satellite cell proliferation. Recent literature questions the utility of ultrasound and notes that some evidence reveals worsening recovery and outcome.16,17
- Heat, whirlpool therapy, and electrotherapy, although pleasing to the patient, have not been shown to influence the rate of recovery from contusions.
Recovery Phase
Rehabilitation Program
Physical Therapy
In the second phase of muscle healing, known as the recovery or regeneration phase, the main feature is proliferation of reserve satellite cells and endomysial fibroblasts, followed by active protein synthesis. The main goal of this treatment phase is restoration of mobility and ROM. Early mobilization of the joint and muscle has been shown to dramatically reduce recovery time and increase tensile strength of the muscle. Early pain-free PROM establishes normal tissue planes, maintains uninjured muscle fiber excursion, and pumps excessive detritus from the soft tissue.
The patient is ready to progress to the next level of therapy when ROM has been restored. Jackson and Feagin found that a patient is ready to move on to the next phase of treatment when 90° of knee flexion is achieved.4
Pain-free PROM of the knee with emphasis on flexion should be encouraged. Gentle isometric muscle exercises can be performed as tolerated. Weight bearing should be allowed as tolerated. Excessive passive stretching of a previously immobilized limb has been shown to produce myositis ossificans in animal models. This potential complication must be balanced against laboratory evidence showing that mobilization demonstrates faster healing times and increased vascularity of the affected tissue.
Occupational Therapy
Individualized education and instruction to adjust the athlete to ADL and routines with the injured limb may be needed to prevent reinjury, and working in conjunction with physical therapy to promote healing is advised.
Medical Issues/Complications
Reinjury is a significant factor in prolonging disability. A fine line exists between a sufficient amount of therapy and too much therapy. Pain tends to be an effective and adequate guide.
Other Treatment (Injection, manipulation, etc.)
Injection of medications into the contused tissue during the recovery phase, and any phase, has not been shown to be beneficial and may in fact be damaging to the tissues; this is especially true of corticosteroids.
Maintenance Phase
Rehabilitation Program
Physical Therapy
The third phase of muscle healing, known as maturation or remodeling, is characterized by a gradual recovery of the functional properties of the muscle, including the recovery of the tensile strength of its connective tissue component. The goal of this phase is to maintain the ROM while restoring full function to the muscle and joint. Progressive resistance exercises are encouraged until full strength and ROM are regained.
Emphasis should be placed on regaining full ROM and restoring strength. Remember that therapy that is too aggressive and too early can result in reinjury caused by muscle strain.
Occupational Therapy
Reevaluation of the patient' s daily activities and increasing tolerance to normal use of the contused limb should be emphasized.
Recreational Therapy
Maintain agility by participation in noncontact sports such as squash, tennis, badminton, and swimming.
Medication
The physician needs to make every effort to relieve pain as completely and expeditiously as possible. Distinguishing the intensity of the pain can be difficult, because it tends to be subjective; therefore, treatment and therapy should be individualized.
Objective parameters, such as tachycardia, are unreliable. Usually, minor trauma to the muscles is self-limited. An enormous selection of analgesics is available for use by the physician, but pharmacologic agents tend to fall into 2 general categories: nonnarcotic and narcotic analgesics. The physician also must consider the best route of delivery of the drug.
Corticosteroids should not be used; they are catabolic, and they inhibit the healing process. These steroids promote overall negative nitrogen balance and loss of muscle. However, these agents continue to be used clinically to treat muscle contusion injuries and are injected into the site of injury to relieve the pain and to expedite a player's return to active status. This inhibition of the inflammatory response may have a sparing effect on the local muscle tissue and, perhaps, on the athlete as a whole in the short term; however, corticosteroids seem to cause an unwanted atrophy of both injured and uninjured muscles.18,22,24
Anabolic steroids may be proven useful in the treatment of contusion injuries because of the effects they have on nitrogen and protein balance and on stimulation of cell synthesis; however, research currently is limited.18 Many sporting governing bodies also control the use of anabolic steroids in their athletes, making the use of these agents controversial.
Nonnarcotic Analgesics
Pain accompanying minor acute soft-tissue injuries may be relieved by a short course of nonnarcotic analgesics with acetaminophen.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Ordinarily, the most commonly ingested pain reliever. Also marketed in combination with other drugs to provide analgesia. Advantages include availability, cost, and relatively high safety profile. The onset of relief is usually within 20-30 min. Extended release preparations do not appear to offer major benefits (other than dosing convenience) and may increase the incidence of toxicity. For children, acetaminophen is available as drops (80 mg/0.8 mL), elixirs (160 mg/5 mL), tablets (80 mg, 160 mg, 325 mg), and suppositories (125 mg, 325 mg).
Adult
650-1000 mg PO q4h; not to exceed 4,000 mg/d PO
Pediatric
10-15 mg/kg/dose PO q4-6h
Rifampin can interact to reduce the analgesic effects of acetaminophen; conversely, barbiturates, carbamazepine, alcohol, hydantoins, zidovudine, and isoniazid may increase acetaminophen hepatotoxicity
Documented hypersensitivity; known G6PD
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with care in patients who are malnourished; hepatotoxicity can occur in those with chronic alcoholism following various dosage levels
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Controversial data exist on NSAIDs. By suppressing the initial inflammatory reaction, the NSAID permits improved performance in early time periods but appears to suppress the stimulus that may be needed for cellular remodeling in longer time periods. NSAIDs also may increase the amount of bleeding within the tissue. Currently, there is a lack of compelling evidence for either argument.
Although acetaminophen is typically listed with NSAIDs, this agent lacks anti-inflammatory properties and is used for its antipyretic and analgesic effects.
A number of NSAIDs are available for use. NSAIDs share a common mechanism of action, inhibiting the production of pain-mediating prostaglandins. Generally, NSAIDs provide a comparable degree of pain and inflammatory relief, but they differ in dosing schedule.
The 5 categories of marketed NSAIDs are acetic acid derivatives, fenamates, oxicams, propionic acid derivatives, and related compounds. Numerous NSAIDs are obtainable over the counter (OTC). Choosing an NSAID to prescribe can be difficult because few data exist that compare these agents, and individual responses are inconsistent. With a lack of evidence that one NSAID proves to be clearly superior, base prescribing decisions on personal experience, safety profiles, cost, and convenience.
Indomethacin (Indocin)
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.
Adult
25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if there is persistent leukopenia, granulocytopenia, or thrombocytopenia)
Ketorolac (Toradol)
Has become the choice of parenteral pain medications dispensed in the ED. Frequently overlooked is the fact that this medication is an NSAID, carrying all its attendant risks, and it is almost 20 times the cost of morphine (and 140 times the cost of ibuprofen). Few data supporting its superiority over other analgesics exist.
Adult
10 mg PO q6h prn
15-30 mg IV/IM q6h prn, give IV dose over 15-30 sec; not to exceed 5 d of treatment
Pediatric
<16 years: 0.5 mg/kg/dose IV/IM q6h; not to exceed 30 mg q6h
>16 years: Administer as in adults
Administered concurrently with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may prolong PT when administered concurrently with anticoagulants; closely monitor PT, and instruct patients to watch for signs and symptoms of bleeding; may increase the risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity); phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into CNS; do not administer to patients diagnosed with peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency or to those patients at high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts rarely occur and usually return to normal in ongoing therapy; discontinuation of the therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occur
Perform ophthalmologic studies in patients who develop eye complaints during therapy; therapy should be discontinued if changes are noted; changes may include blurred or diminished vision, corneal deposits, retinal disturbances, scotomata, changes in color vision, and macular degeneration
Ibuprofen (Motrin, Advil, Nuprin)
This prevalently used NSAID, also available OTC, is a derivative of the propionic class of NSAIDs and is considered the safest of the NSAIDs. Available as tablets of 200 mg, 400 mg, 600 mg, and 800 mg. Pediatric dosage forms are available as both a tablet and oral suspension (20 mg/mL). Advise taking ibuprofen with food or milk, if possible. Prescribe with caution in children with flulike illnesses.
Adult
400-600 mg PO q6h
Alternative dosing: 800 mg PO q8h
Pediatric
30-50 mg/kg/d PO divided qid; not to exceed 2400 mg/d
Increased toxicity if used with oral hypoglycemic agents, phenytoin, and warfarin; interferes with ACE inhibitors and beta-blockers; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of loop diuretics when administered concurrently; PT may increase when administered concurrently with anticoagulants; closely monitor PT, and instruct patients to watch for signs and symptoms of bleeding; ibuprofen and other NSAIDs may increase serum phenytoin and lithium levels as well as risk of methotrexate toxicity
Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients in whom aspirin, iodides, or other NSAIDs induce hypersensitivity; do not administer to patients diagnosed with peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency or to those patients at high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function
Narcotic Analgesics
Patients complaining of inadequate pain relief from NSAIDs may benefit from short-term supplementation with an opioid compound. A wide array of products is available.
Orally (PO), hydrocodone (eg, Lortab, Lorcet, Vicodin, Anexsia), a schedule III narcotic, and oxycodone (eg, Roxicet, Percodan, Tylox), a schedule II substance, usually provide additional pain relief. Codeine-containing products (schedule III drugs) are not as reliable for alleviating pain. Although the relative potency for oxycodone and hydrocodone is approximately 0.33 (compared with parenteral morphine), that for oral codeine is 0.05. Mixed agonist-antagonist oral agents, such as butorphanol, nalbuphine, and pentazocine, offer no real advantages to opioid agents; yet, they cause a higher incidence of adverse effects. Common side effects include constipation, nausea, respiratory depression, sedation, and urinary retention.
Generally, the approved dosage of hydrocodone is 5-10 mg, combined with 500-750 mg of acetaminophen and taken PO every 6 hours as needed (q6h prn). Oxycodone analgesic preparations typically combine 2.5-5 mg of oxycodone with 325 mg of acetaminophen. They are dosed as 1-2 tablets PO q4h prn for moderate to severe pain. Acetaminophen with codeine (Tylenol #3) contains 30 mg of codeine with 325 mg of acetaminophen. Usually, 1-2 pills q4h prn is recommended.
Elixirs containing hydrocodone (Hycodan) are convenient for children older than 6 years who have moderate to severe pain and who are unable to swallow pills. One teaspoon (5 mL) of Hycodan contains 5 mg of hydrocodone; the dose usually is 1.25-2.5 mg q4h, depending on the child's size and the severity of pain. The elixir of Tylenol with codeine for children contains 120 mg of acetaminophen and 12 mg/5 mL of codeine in an alcohol base (7%).
Generally, orally administered drugs impart a slower onset of action. For patients in severe pain or for those patients who must take nothing by mouth (NPO), parenteral agents may be necessary. Although the intramuscular (IM) route may be more convenient for the staff, the intravenous (IV) route offers a number of advantages. Narcotics given IV provide a rapid and predictable onset of action and are easier to titrate. Morphine and meperidine are the most commonly used parenteral narcotic agents.
Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab, Anexsia)
A drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h
Single dose not to exceed 10 mg of hydrocodone bitartrate; do not exceed 5 doses in 24 h
Phenothiazines may decrease its analgesic effects; conversely, the toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants
Documented hypersensitivity to acetaminophen or hydrocodone bitartrate; patients with elevated intracranial pressure
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Tablets contain metabisulfite, which may cause allergic reactions; administer with caution in patients dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction; use with caution in elderly persons
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease the analgesic effects of this medication; conversely, its toxicity increases when administered concurrently with either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of the patient's total daily dose of acetaminophen; maximum dose of acetaminophen is 4000 mg/d, higher doses may cause liver toxicity
Acetaminophen and codeine (Tylenol #3)
A drug combination indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose PO (based on codeine content) q4-6h or 1-2 tab q4h; not to exceed 12 tab/24h
Pediatric
0.5-1 mg/kg/dose PO (based on codeine content) and 10-15 mg/kg/dose PO q4h (based on acetaminophen content); not to exceed 2.6 g/24h
Toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants
Documented hypersensitivity to acetaminophen or codeine phosphate
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Administer with caution in patients dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction
More on Contusions |
| Overview: Contusions |
| Differential Diagnoses & Workup: Contusions |
 Treatment & Medication: Contusions |
| Follow-up: Contusions |
| Multimedia: Contusions |
| References |
| Further Reading |
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References
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Further Reading
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Keywords
contusions, bruises, bruising, muscle contusions, hematomas, soft-tissue injuries, ecchymosis, myositis ossificans, heterotopic ossification, compartment syndrome
