contusions, hematomas, myositis ossificans & decubitus ulcers

Question 1

What are the classifications of contusions?

Answer 1

• mild
• moderate
• severe

Question 2

Describe a mild contusion

Answer 2

• minor crush injury with minimal bleeding
• minimal to no loss of strength
• minimal loss of ROM
• can continue with activity with mild discomfort
• 5-20% loss of ROM with minimal loss of strength

Question 3

Describe a moderate contusion

Answer 3

• moderate crush injury with bleeding and swelling
• difficulty continuing with activity due to pain and muscle weakness; disability the next day
• 20-50% loss of ROM and moderate loss of strength

Question 4

Describe a severe contusion

Answer 4

• severe crushing injury with rapid bleeding and swelling
• cannot continue with activity due to significant pain and muscle weakness
• more than 50% decrease in ROM and functional loss of strength

Question 5

Describe acute symptoms of contusions

Answer 5

• bruising is red, black and blue
• decreased ROM due to swelling and protective muscle spasms
• pain at rest
• inflammation (heat, redness, pain, swelling)
• tenderness at site of lesion

Question 6

Describe early sub-acute symptoms of a contusion

Answer 6

• bruising is black and blue
• pain, edema and inflammation are still present but reduced from the acute stage
• adhesions are developing around the injury
• protective muscle spasming decreases but tps occur in affected muscles and the synergist and antagonists
• ROM is still reduced/increased pain on mvmt

Question 7

Describe late cub-acute symptoms of contusions

Answer 7

• bruising is yellow, green and brown
• pain, edema and heat diminishes
• adhesions are developing around the injury
• protective muscle spasm is replaced by increased tone and tps in affected and compensatory muscles
• ROM and strength are reduced
• periperal nerves may be compressed by edema and swelling

Question 8

describe chronic symptoms of contusions

Answer 8

• bruising is gone
• adhesions are mature
• hypertonicity and tps are present in affected muscles and compensatory structures
• tissue may be cool due to ischemia
• moderate to severe - discomfort local to the lesion when muscles is stretched; full ROM and strength may still be reduced
• myositis ossificans can be produced within 3-6 weeks post injury

Question 9

CI’s for contusions

Answer 9

• in acute of moderate to severe contusion NO PROM OR RROM are done to prevent further tissue damage
• in acute of mild contusion - no onsite work
• acute and early subacute in moderate to severe - local and swedish massage is CI’d but proximal MLD is indicated
• avoid removing protective splinting of acute contusion
• first 10 days with moderate to severe - no heat or contrast bathing or vigorous treatments
• no circulatory techniques toward injury because of congestion of area
• no stretch or PROM beyond onset of discomfort
• frictions if client on anti-inflammatory or blood thinners

Question 10

Define Hematoma

Answer 10

• a localized collection of blood, usually clotted, in a tissue or organ.
• almost always present with a fracture

Question 11

What is a contusion?

Answer 11

• a crush injury to a muscle (without breaking the skin)
• damage to the mm fibers and bleeding into the subcutaneous tissue and skin
• can be local with minor discoloration to large and debilitating
• bruising can track along the fascial planes
• periosteum can be contused
• is caused when blood vessels are damaged or broken as the result of a blow to the skin
• a purplish, flat bruise that occurs when blood leaks out into the top layers of skin is referred to as an ecchymosis

Question 12

What causes myositis ossificans?

Answer 12

• not applying cold therapy and compression immediately after the injury
• having intensive physiotherapy or massage too soon after the injury.
• returning too soon to training after exercise

Question 13

symptoms of myositis ossificans include:

Answer 13

-restricted ROM
-pain in muscle when you use it
-strength loss
-a hard lump in the mm/palpable mass within tissue
an x-ray can show bone growth

Question 14

precautions and management of myositis ossificans

Answer 14

• avoid use of deep pressure directly over severe bruises - this can aggravate the injury site and cause more production of bony material and a larger mass to form
• do not try to increase ROM of the surrounding joints while it is still in acute or subacute stage - this can be painful and may also aggravate the injury
• have patient rest the area as much as possible until maturation of the mass occurs

Question 15

observations for an acute contusion

Answer 15

• antalgic gait
• bandages/tensors to manage swelling
• antalgic posture
• edema at lesion site
• red, black or purple bruising

Question 16

observations for subacute contusions

Answer 16

• edema diminishes from the early to late subacute stage, both on site and distally
• bruising over the injury site changes from purple and black in early subacute stage to brown, yellow and green in late subacute
• contusions that occur in the distal thigh may drain down to the knee and produce local irritation

Question 17

observations for chronic contusions

Answer 17

• habituated antalgic gait and posture

- with a severe contusion, there may be an alteration in the contour of the muscle

Question 18

What will you palpate with an acute contusion?

Answer 18

• heat over the injured muscle and possibly in the surrounding tissue
• tenderness is present local to the lesion site and refers into the nearby tissue
• texture of the edema is firm
• protective mm spasm is present in the affected mm, the synergists, and the antagonists

Question 19

What will you palpate in a subacute contusion?

Answer 19

• temperature diminishes
• tenderness is present local to the injury
• texture of the edema is less firm
• adhesions are present as the healing progresses from early to late subacute
• trp may be present

Question 20

What will you palpate in a chronic contusion?

Answer 20

• injury site may be cool due to ischemia
• point tenderness at the lesion site
• adhesions and fascial restrictions are present local to the injury site
• hypertonicity and trps are present local to the injury and in compensating mm.
• IF myositis ossificans is present, there is local inflammation and the bony island is palpable as a hard, unyielding nodule

Question 21

What will the mvmt be like with an acute contusion?

Answer 21

• AFROM is reduced
• if moderate or severe suspected other testing is CI’d in acute phase
• PROM - painful, mm spasm end feel
• AROM - mild-minor to no loss of strength with some discomfort

Question 22

What will mvmt be like with a subacute contusion?

Answer 22

• AFROM & PROM - reduced

- RROM - pain at injury side

Question 23

What will mvmt be like with a chronic contusion?

Answer 23

• AROM - may be limited by any remaining pain at the end ranges of motion
• PROM - mildly painful, tissue stretch end feel on fully stretching the affected mmm
• RROM - may reveal decreased mm strength

Question 24

What special tests do you use with acute, subacute or chronic contusions?

Answer 24

• acute - girth measurement test
• subacute - AROM, PROM, isometric testing, quad contusion test
• chronic - length tests

Question 25

What is a decubitus ulcer?

Answer 25

• aka. “pressure sores”
• skin lesions caused by an external pressure,shearing or friction force that is sufficient to locally impair circulation and lymphatic flow in susceptible individuals
• lesions may result in ulcerations

Question 26

What does low pressure do to decubitus ulcers?

Answer 26

can cause tissue damage if it is applied over several hours

Question 27

what does higher pressure do to decubitus ulcers?

Answer 27

can cause tissue damage in only a few minutes

Question 28

Decubitus ulcers lead to…

Answer 28

• ischemia and irreversible tissue damage due to a deficiency of oxygen to the cells and retention of toxic metabolic waste.
• serious if left untreated, can lead to septicemia or even death

Question 29

What can cause decubitus ulcers?

Answer 29

unrelieved pressure, friction, humidity, shearing forces, temperature, age, continence and medication to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, ankles, etc.

Question 30

what are contributing factors to decubitus ulcers?

Answer 30

• sensory perception and motor losses, which are present with people who have neurological disorders, such as spinal cord injuries
• severely compromised tissue health
• incontinence - inadequate protein intake & vitamin deficiencies such as vit C or B12, iron and zinc
• medication - including tranquillizers, sedatives and opiates

Question 31

Describe a stage 1 symptom picture for decubitus ulcers

Answer 31

• earliest stage of a pressure sore is evident with local erythema
• palpable warmth
• hardened swelling over the fragile but intact tissue
• redness in areas where pressure is applied will diminish upon release often w/in a few minutes
• reversible but require intervention
• visually similar to reactive hyperemia. can be distinguished in two ways: 1) reactive hyperemia resolves itself w/in 3/4 of the time pressure was applied, 2) reactive hyperemia blanches when pressure is applied, whereas a stage 1 pressure ulcer does not.
• the skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient

Question 32

Describe a stage 2 decubitus ulcer symptom picture

Answer 32

• more tissue damage occurs, with the epidermis and often the dermis being affected
• classified as partial-thickness damage
• blister, abrasion or shallow ulcer may be present
• area is moist, pink and painful

Question 33

Describe a stage 3 decubitus ulcer symptom picture

Answer 33

• full-thickness damage down to subcutaneous layers
• cavity is created
• may be exudate and a crust over the cavity
• crust is referred to as eschar, is thick and leathery necrotic tissue
• can be difficult to heal due to poor blood supply to this layer

Question 34

Describe a stage 4 decubitus ulcer symptom picture

Answer 34

• most severe lesion includes not only full-thickness tissue damage but also necrosis to underlying muscle and bone
• deep cavity may be covered with a crust and lead to sepsis.