1. Contusions
Presentation
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:
• 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:
o resting the affected part,
o immobilization (the ultimate in rest, best achieved with a splint),
o elevation of the affected part (ideally, above the level of the heart), and
o 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:
• 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 follow up and .

2. 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
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.