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GENERAL APPROACH TO FRACTURES DIAGNOSIS: Hx, Px, Xrays (splint obvious fractures b/f Xrays) REDUCTION: Increase deformity, traction, replace, MUST do post reduction Xray IMMOBILIZATION: Non-operative (cast, splint), Operative (internal, external fixation) REHABILITATION CLINICAL FEATURES History Pay particular attention to mechanism of injury MOI crucial b/c some injuries are not evident on Xray Physical LOOK: swelling, deformity, open fracture site FEEL: pain, tenderness, swelling (palpate well away from injury) MOVE: ROM, loss of function, crepitus NEUROVASCULAR examination PLAIN RADIOLOGY Obvious fractures should be splinted before Xray Xrays do NOT r/o fracture May not appear until the # margins absorb Absorption will widen the radiolucent line and the defect will present at 710d New bone beneath the fracture will accentuate the defect Treat as fracture and reXray at 7-10d if suspicions Rule of Twos 2 views: AP + lateral (MUST have both) 2 joints: joint above and below 2 times: b/f and a/f reduction 2 sides: opposite sides esp. in children to compare growth plates CODE of Xray Quality C...coverage (joint above and below) O...orthogonal views DE...decent exposure ABCs of reading the Xray Alignment, Bones, Cartilage, Soft tissues, Second abnormality, Stability Description of Fractures: O-S-T-L-A-R-D-O (exact anatomic location) T...type (transverse, oblique, spiral, comminuted, segmented, torus, greenstick) L...length A...angulation (deviation from longitudinal axis; describe amount in degrees; describe direction of apex if in midshaft and direction of distal fragment if at end) A....intra-articular (% of joint surface involved) R....rotation (clinical examination) D....dislplacement (% of offset) O....other (impaction, avulsion, pathologic, valgus, varus)


Pathologic: tumors, osteomalacia, Rickets, scurvy, osteogenesis imperfecta, osteoporosis as a result of another condition (polio) Valgus: angled away from midline Varus: angled toward midline Fracture mimicers Nutrient artery: fine, sharply marginated, oblique course through cortex, less radiolucent than fracture Pseudo#: soft tissue folds, overlying material, Mach effect (artifact) Avulsion (irregular, uncorticated surface, defect in adjacent bone) versus accessory ossicle or sesamoid bones (smooth, corticated surface)

OTHER RADIOLOGY Bone scan: TC99, osteomyelitis, fractures, tumors; fracture must be 1-2 days old (preferably 10), lacks specificity b/c will pick up inflammation CT: good if uncertain or for description of articular surfaces MRI: soft tissues AVOIDING ORTHOPEDIC PROBLEMS History and MOI will predict most injuries Normal Xrays do NOT r/o fracture Do NOT accept inadequate films Xray and examine joint above and below Xray before reduction unless vascular compromise N.V. examination essential before and after ANY manipulation Splint while waiting Xrays and ortho Specific discharge instructions

GENERAL CARE Splint all fractures ASAP (prevents further injury and conversion to open # as well as relieves pain and facilitates trnpt) Gentle traction to align limb b/f splinting if malaligned Immobilize joint above and below Do not remove splint in ER; loosen and reapply if neurovasc injury Every XR should have splint Definitive care = reduction and immobilization NONOPERATIVE FRACTURE CARE Most #s managed nonoperatively Indications = NO indication for operative management Non-displaced or minimally displaced #s: immobilization Non-articular displaced #s: closed reduction and immobilization Methods of immobilization Plaster of Paris: most common, main use for upper extremities and below mid thigh, slabs or circumferential cast, watch out for tight cast causing a compartment syndrome Fiberglass: lighter, strong, water resistant, difficult to mold, expensive Traction: skin or skeletal traction, most commonly used for femur #s and some pelvis #s (vertical shear), traction pins in distal femur, proximal tibia, olecranon, C-spine Slings, splints, bandaging Complications of Casts Pressure sores (warning is pain, decreased LOC :. require Sx) Compartment syndrome from tight cast (split immediately) Joint stiffness Neuroparaxia esp w/ below knee cast pressing peroneal n. DVT from immobilization Complications of Traction Bed confinement Pressure sores Peroneal nerve palsy when knee rests against side of splint Neurovasc str damaged by traction pins Pin infection or loosening Discharge instructions RICE Rest Ice Elevation: MUST be above the level of the heart Dont rest plaster on anything b/c it takes 24hrs to fully set Watch fingers and toes for excessive swelling, decreased sensation, cyanosis Follow up instructions

OPERATIVE FRACTUE CARE Strong, stable fixation by Sx allows earlier mobilization because it limits loss of function due to

scarring and secondary joint stiffness prevented by early mobilization General Indications for operative treatment Anatomical reduction is reqd: intraarticular #s, prevents deformity and posttraumatic arthritis, closed reduction rarely produces anatomical reduction Multi-traumatized Pt Immobilization is undesirable (elderly b/c of complications Failure on non-operative Tx (failure to obtain or maintain reduction) Open fractures (require debridement) Fractures known to be unstable Femur Fracture Floating Knee/Elbow Compartment syndromes or vascular injuries Pathological # secondary to bone mets: internal fixation relieves pain and allows return to home Economics Methods of operative treatment Internal fixation: screws, plates, wires, staples, intramedullary devices External fixation Amputaiton Complications of operative tx Further injury Neurovascular injury Infection Bone too weak for good fixation Delay in # healing, failure of hardware, loss of stability Second operation risks when hardware is removed Refracturing of bone if hardware removed too early or if another injury occurs b/f screws stable (6wks)

INTRODUCTION Open = Compound = communication b/w bone and outside env Comminuted = many fragments Limb threatening :. surgical emergency Most important management factor is prevention of infection Infection rate rises w/i 6hrs and debridement should be done w/i this time Bone and Soft tissue injuries are usu worse than w/ closed #s They tend to have a great deal of periosteal striping and devascularization of bone leading to dead bone which is at high risk for infection Any fracture with a wound MUST be assumed to be an open fracture even if the wound is not located right overtop the suspccted fracture site. Dont do the paper clip trick. MANAGEMENT ALL require debridement thus EMERGENT orthro consult Treat wound and fracture simultaneously

Thorough debridement is the MOST IMPORTANT first step Describe wound: location, size, contamination, extent of muscle damage, neurovascular exam Gross Debridement; pick out gross contamination only; further debridement is done in OR Never probe a wound in the ER to determine if it is down to bone Attempt reduction if the bone protrudes through the skin Apply sterile dressing and DO NOT REMOVE IT Splint, elevate, remove constrictive clothing, jewelry Tetanus prophylaxis and Analgesia Keep patient NPO Antibiotics Start ASAP after swabs obtained CLEAN: d of c is first generation cephalosporin such as cefazolin (Ancef) which gives wide coverage including staph DIRTY: add aminoglycoside for gross contamination to cover gram -ves (Gentamycin/Tobramycin) FARM: add Pen G if high risk of gas gangrene (C. perfringens) such as farm injury Antibiotics never take the place of debridement Stabilization internal/external fixation decreases mvmt thus prevents further soft tissue damage and decreases infection rate wounds are also easier to debride, change dressings, and graft than working around a traction device fixation allows for earlier mvmt and rehab wounds should be left open and undergo a delayed primary closure or coverage (skin graft/flap) when it is sure that there is no infection (7/7)

COMPLICATIONS Same as for closed fractures but more frequent b/c injuries are more severe

DEFINITIONS: LUXATION=Dislocation = complete disruption of the joint so that the articular surfaces are no longer intact SUBLUXATION = partial disruption where a portion of the articular surface remains in contact Defined by joint involved; in three bone joints, defined by the lesser joint involved Should be described by the direction of the distal fragment Fracture dislocation denotes associated fracture Also described as open or closed SIGNS AND SYMPTOMS Pain Deformity: may not be obvious (ex: posterior shoulder0 Skin disruption Position - hip: flexed, adducted, internal rotated Neurovasc injury: common with certain dislocations (knee and popliteal artery) Loss of active and passive mvmt: test gentle ROM but do not force

MANAGEMENT General principles: the sooner the better b/c swelling and muscle spasm make reduction more difficult with time; analgesia aids reduction; some joints cannot be reduced in ED Vascular compromise ............reduction attempted BEFORE Xrays Otherwise .............................Xrays done BEORE reduction Reduction accomplished by traction in the line of the deformity and then gentle manipulation EMERGENCY...........many are limb threatening MUST repeat Xrays after reduction to assess reduction and look for fractures

BONE STRUCTURE Matrix - mostly collagen which gives tensile strength, collagen offers NO resistance to compression Mineral - hydroxyapatite resists both tensile and compressive forces, stronger in compression than in tension FRACTURE MECHANISM Many fractures are on the tensile side of the bone b/c bone is more resistant to compressive than tensile forces. Viscoelasticity makes the RATE of application of stress a major factor in determining the fracture pattern and soft tissue injury HIGH energy high strain, dissipation produces xplosion LOW energy low strain, produces linear fracture DIRECT BENDING: transverse fracture, triangular fragment (wedge fragment or butterfly) may be extruded on the compression side BENDING + AXIAL COMPRESSION: oblique fracture TWISTING: spiral fracture PURE COMPRESSION: seen in cancellous bone with a thin cortical shell (metaphysis, vertebral bdies, os clacis), cortical bone is resistant, fracture b/cms more fragmented as E increases TENSILE: occurs in thin cortex subject to high forces (patella, olecranon when muscle contracts while limb is flexed). Also, medial malleolus pulled off by the deltoid ligament as eversion and external rotation forces are applied to the ankle. Fractures are transverse, occurring at right angles to the tensile force and producing only 2 fragments COMBINATIONS FRACTURE HEALING Healing by Callus fromation Inflammatory Phase (10% of total time): bleeding, clot formation , acute inflammatory rxn, VD, exudation, histiocytes, mast cells Reparitive Phase (40% of time):bone ends dead and do not participate hematoma organization, invasion of fibrovascular tissue from cambium layer of periosteum, endosteal bone surface, and soft tissue ----- replacement of clot w/collagen and matrix, mineralization of this forms the PRIMARY CALLUS which is woven bone; cartilage forms in the callus periphery which will later be converted to bone by endochondral ossification; similar process occurs in the

medulla until union occurs Remodelling Phase (70%): begins b/f union achieved and continues for years; same as in normal bone: osteoclastic resorption and laying down of new bone along the lines of force (Wolffs Law ) Primary (Direct) bone healing Contact healing occurs when surfaces are held together under conditions that do NOT allow mvmt (usu by plates and screws) Occurs WITHOUT callus formation Cutting cones (heads) have osteoclasts which drill holes into long axis and are followed by osteoblasts creating new osteons Forms new lammellar bone along the lines of force Bone remains weaker for 18mo

HEALING COMPLICATIONS Nonunion = fragments fail to unite, mechanical dysfuction and pain Psuedoarthosis = nonunion results in a false joint Delayed union = takes extra time to unite and may progress to nonunion Malunion = bone heals in an undesirable position b/c the initially acceptable reduction displaces Intraarticular malunion leads to post traumatic arthriits Nonarticular malunion leads to malalignment (imp in femur and tibia), loss of mvmt, and function INFECTIONS Open fractures are surgical emergency b/c of risk of infection Cover wounds with sterile dressing and give IV abx ASAP Grade I: ancef iv (add gentamycin for Grade II/III) Usefulness of culture and sensitivity of wound doubtful Box 42-2 HEMORRHAGE Pelvic fracture: 1500 - 3000 ml Femur fracture: 1000 ml Tibia/fibular: 500 ml Humerus: 250 ml Radius/ulna: 200 ml VASCULAR INJURY Vascular examination critical Examination may be difficult with massive swelling Document presence of pulse AND capillary refill Look for pallor, pulseless, polar, paresthesias, paralysis, pain Incomplete and subclinical vascular injuries can be initially asymptomatic and undetectable Doppler should be used if pulses are not palpable Distal pulses may be present in 10 - 15% of significant arterial injuries Arteriography or exploration may be necessary Complications: thrombosis, AV fisutula, aneurysm, false aneurysm, ischemia, Volkkmans

ischemic contracture, infarction, loss of limb, rhabdomyolysis, compartment syndrome AVASCULAR NECROSIS Necrosis due to poor blood supply after fracture Especially is fracture comminuted, untreated for any length of time Risky areas Femoral head, Talus, Scaphoid, Capitate COMPLICATIONS OF IMMOBILIZATION Pneumonia, DVT, PE, UTI, wound infection, decubitus ulcers, muscle atrophy, stress ulcers, GI hemorrhage, psychiatric disorder,

NERVE INJURY Neuropraxia Axonotmesis Neurotmesis

Contusion of a nerve with disruption of ability to transmit impulses Paralysis if present is transient and sensory loss is minimal Normal function usually returns w/i weeks to months More severe crush injury to a nerve Injury to nerve fibers occurs w/i their sheaths Schwann tubes remain in continuity :. spontaneous healing is possible but slow

Severing of a nerve usually requiring surgical repair Classic associations ...... Elbow injury median or ulnar nerve Shoulder dislocation axillary Sacral fracture cauda equina Acetabular fracture sciatic Hip dislocation femoral Knee dislocation tibial or peroneal Lateral tibial plateua peroneal Severed nerve: all function will be absent; all sensory and motor Less severe injuries often have preservation of function Light touch is a good screening test Two-point discrimination more sensitive and should be routinely done in digits (less useful in children, uncooperative, comatose, severe pain) ORiain wrinkle test for sympathetic nerve function: soak digits in warm saline for 20 min will cause the digital pulps to wrinkle through a mechanism not well understood; wrinkling denotes intact nerve function; absence is more difficult to interpret Ninhydrin sweat test: sudomotor test for nerve funtion but not practical for emerg

FAT EMBOLISM SYNDROME Fat globules embolize to lung and through peripheral circulation Subclinical FES likely very common; clinical syndrome fairly uncommon 1% of long bone fractures and 5-10% of multiple trauma patients Long bone fractures (Tibia and fibula) in young adults Hip fractures in elderly Symptoms 1 - 2 days after injury or surgery Triad of decreased LOC, respiratory distress, petechiae

Respiratory distress: earliest symptom, most common and severe Decreaesed LOC: restlessness, confusion, seizure Petechial rash from thrombocytopenia Other: fever, tachycardia, jaundice, retinal changes, fat in urine in 50% by day3 Management supportive; no specific therapy

FRACTURE BLISTERS Tense blister or bullae in areas of minimal skin coverage like the ankle, elbow, foot, knee These areas contain fewer hair follicles and sweat glands to anker the skin Occur with high underlying pressure and may be a marker for compartement syndrome Early surgery and minimizing tissue pressure reduces the incidence COMPLEX REGIONAL PAIN SYNDROMES Reflex sympathetic dystrophy (RSD) and Causalgia = terms used to define pain syndromes that sometines follow fractures, ortho surgery, and other limb ins Many other names: Sudecks atrophy, shoulder-hand syndrome, postinfarction sclerodactyly International association called RSD = Complex Regional Pain Syndrome type I (CRPS I) Pain syndrome after an initiating noxios event, extends beyond the distribution of a single peripheral nerve and is usally disproportionate to the inciting event Site is most often the distal end of the affected extremity with distal to proximal gradient Associated with edema, poor blood flow to skin, abnormal sudomotor activity, allodyna (pain from proximal stimulus), hyperpathia (pain after mild light pressure), or hyperalgesia Causalgia = CRPS II Identical to RSD except that there is demonstrable peripheral nerve injury Pathogenisis Not well known Sympathetic nervous system involved in some but not all Pathological tissue changes demonstrated in most; usually not malingering Does occur in pediatrics Diagnosis No correlation b/w severity of initial trauma and symptom severity Early diagnosis is difficult especially with minimal trauma Earlier treatment is more effective RSD symptoms abolished with sympathetic blockers very suggestive 9 point clinical scale: 1 point if present, point if equivical ---------> RSD if > 5 Allodyna or Hyperpathia Burning sensation Edema Color or hair growth changes Sweat changes Temperature changes Xray changes (demineralization) Vasomotor or sudomotor quantitative measurement change Triple phase bone scan consistent Treatment Controversial Sympathetic blockade, regional anesthesia, surgical sympathectomy Calcitonin, vitC, TCA, indomethacin have been tried

COMPARTMENT SYNDROME Introduction Defintion - pressure w/i compartment > pressure of capillary bed producing local ischemial and may result in necrosis if not treated 6 hour limit b/f necrosis MC sites: forearm, leg Other sites: thigh, foot, buttock, shoulder, arm, hand MCC is direct trauma and fracture Closed fractures more common that open fractures Compartment syndromes can occur in open fractures Most common location is closed fracture of the tibia but is well described in thigh, forearm, hand, foot Can occur with soft tissue injury w/o fracture (shin splints, limb compression while unconscious, etc) ------> one study had 30% with NO fracture (STI only) Unusual causes: lithotomy position, tuck position, spontaneous hemorrhage, MAST trausers, excessive traction for treatment of a fracture Other causes: soft tissue injury w/o # (crush injury), post ischemic swelling following restoration of blood flow a/f arterial repair, embolectomy, tourniquet release, drug OD w/ prolonged limb compprssion, extremity burns esp circumferencial escar Etiology (Box 42-2): Increased Compartment Content Bleeding: vascular injury, coagulopathy, anticoagulant Rx Increased capillary filtration trauma: fracture, contusion, convulsion excessive muscle use: excersize, seizure, eclampsia, tetany burns: thermal, electrical reperfusion injury: bypass, embolectomy, coronary cath, lying on limb, ergotamine ingestion intraarterial drug injection ortho surgery snakebites Increased capillary pressure intensive use of muscles venous obstruction: phlegmasia cerulea dolens ill - fitting leg brace venous ligation diminished serum osmolarity (nephritic syndrome) Decreased Compartment Volume Closure of fascial compartments Excessive traction on fractured limb External Pressure Cast, Dressing, Splint, Lying on limb Miscellaneous Infiltration, pressure transfusion, leaky dialysis cannula, muscle hypertrophy, popliteal cyst

Pathophysiology Tissue pressure rises, venous pressure rises, compromise of local blood flow and hypoxia occurs Occurs at pressures that are above diastolic pressure but below arterial pressure b/c of reduced arteriovenous gradient at the tissue level Body responds by increased blood flow to area; inflammatory mediators cause membrane permeability, fluid leak, and increasing edema and pressure Pressure increases above capillary perfusion pressure and venous flow is impaired Finally arterial flow is compromised ----------> ischemia and necrosis Elevation of limb may exacerbate compartment syndrome: elevation of a limb decreases arterial pressure (0.8mmHg/cm) but venous pressure does not decrease (because it is essentially the same as the compartement pressure) ---------> decrease in arterial - venous gradient and decrease perfusion :. level of heart is best Vascular spasm plays a minimal role Normal compartement pressure is 0 mmHg Compartment pressures that lead to compartment sydrome vary b/w individuals; in general, ischemia develops when compartment pressure is w/i 10 - 30 mmHg of diastolic pressure Ischemia depends on pressure AND duration Measuring compartment pressures :. are not 100% reliable History Onset from hrs to days a/f injury Pain out of proportion to injury is KEY feature that should raise suspicion (BEWARE OF THE WIMP - request for more anesthesia is a clue) Pain is the first symptom; may be described as a tightness, burning, deep Obviously unreliable in decreased LOC, intoxicaiton, etc Paresthesias Physical Findings Limited active movement (b/c of pain) Passive streching causes pain Hypesthesia and paresthesia: decreased two pt discrimination in the distribution of the nerve running through that particular compartment Swelling and Tenderness of entire compartment Firm compartment: soft compartment extremely unlikely to be this Absence of peripheral pulses and five Ps: VERY LATE FINDING and is a very poor diagnostic sign; only occurs when there is irreversible ischemia, occurs when compartment P > SBP Diagnosis Clinical diagnosis Stryker device: hand-held digital display, must zero, must hit appropriate compartment, pressures < 30 will generally not produce syndrome, P > 30 or w/i 30 of systolic pressure are operative indications; serial measurements if unsure Doppler not useful Angiography: do if suspecting any arterial injury ** MUST re-examine patient b/c it may not be present initially ** ** Just b/c they dont have one initially DOES NOT mean a compartment synd wont devp**

Management Place limb at heart level (NOT higher b/c aterial pressure will dec; venous doesnt) Cut casts and dressing along length; remove do not improve w/i 30-60 min Sugical decompression (complete fasciotomy) indicated for high clinical suspicion (even w/o compartment pressure measurement) ** BE AGRESSIVE - a few needless fasciotomies better than missed dx** Complications Infection, gangrene, limb amputation Fibrosis: major local complication if untreated or delayed tx; muscle fibrosis and joint contractures and impaired nerve function; fibrotic muscle incision, contracture release, neurolysis, tendon transfers help but do NOT return a normal limb Crush Syndrome: large amount of ischemia/necrosis, myoglobin release, urine turns red-brown, precipiation of myoglobin in renal tubules and ACUTE RENAL FAILURE, can be fatal


SPRAINS Definitions Assessment Sprain = ligamentous injury resulting form an abnormal motion of a joint Injury to the fibers of a supporting ligament of a joint First degree: minor tearing with resultant hemorrhage and swellin, minimal point tenderness, stressing produces some pain but NO opening or abnormal joint motion Second degree: partial tear involving more fibers, moderate hemorrhage and swelling, painful motion, abnormal motion, loss of function, may be tendancy toward persistent instability and recurrence Third degree: complete disruption of ligament, more bleeding/swelling, more painful motion/abnormal motion/loss of function, stressing the joint will reveal grossly abnormal joint motion; chronic instability common Snap or pop sound sometimes heard MOI important Xray to r/o fracture in majority of cases Examination should include stressing the joint to demonstrate abnormal motion Avulsion fractures common with sprains

Management NSAIDs, Ice, rest, elevation Immobilization: early immobilization, reexamination at 3 days to assess injury Complete, 3rd degree sprains: f/u with ortho in one week Admission for elderly who cannot ambulate safely Sprains can be significant, have long duration of recovery, have permanent complications so dont minimize to patients

STRAINS Nomenclature Assessment Management

Strain = injury to a musculotendinous unit (pulled muscle) First degree: minor tearing, swelling, tenderness, loss of function Second degree: more fibers involved but not complete disruption Third degree: complete disruption separating muscle from muscle, muscle from tendon, tendon from bone Avulsion fractures can occur Pain, swelling, echymosis, tenderness Stretch force to muscle, active or passive, will reproduce pain Palpable defect sometimes present Common in overuse in those who are unfit Mechanism gives clue to injury: push off and achilles strain First degree: rest, ice, elevation, NSAIDs Second degree: similar but longer time before return to activity Third degree: ortho consult b/c some can be operatively repaired; some managed with immobilization

TENDINITIS Tendinitis = inflammatory condition characterized by pain at tendinous insertions into bone occurring with overuse More complex pathophysiology than simply oversuse Aging, poor blood supply, decreased tensile strength, muscle weakness, muscle imbalance, poor flexibility, obesity, malalignment, training errors, improper equipment, PMHx: DM, CRF, RA, SLE, steroids Tendinosis may be better term for chronic conditions Calcium deposits along the tendon can result in calcific tendinitis Pain, limited motion, tenderness, crepitus over tendon Forced muscle strength testing against resistance should increase pain Xrays may show avulsion, calcium deposits Ultrasound can demonstrate tendonitis Rest, Ice, NSAIDs followed by rehab and training No evidence that NSAIDs alter pathophysiology of condition Corticosteroid injection BURSITIS Bursitis = inflammation of the bursa that may be traumatic or infections Olecranon, greater troch of femur, prepatellar are most common Tenderness, swelling, warmth, erythema Aspiration if infection suspected Conservative tx unless infected

SPLINTING AND BANDAGING Splinting suspected fractures/dislocations prevents further damage, may restore blood flow to ischemic tissue by removing pressure, relieves pain by preventing movement Prehospital

Splint should be applied in field Commercial splints available Some avoid air splints b/c of contribution to compartment syndrome Splint before patient is moved Severly angulated fractures should be straightened b/f they are splinteed Immobilized joint above and below, pad skin to avoid necrosis, avoid constriction Sling-and-Swath Bandage and Velpeau Bandage: immobilize shoulder, humerus, elbow Clavicle splint: figure of eight has not been shown to be better than simple sling Plaster splints: good for elbow, forearm, wrist, hand Femur and hip Hare traction splint or similar device: apply prehospital Sager splint: more acceptable for use in the presence of pelvic # and avoids compression on sciatic nerve Knee Comercial devices Jones compression dressing Ankle: plaster splint, adhesive strapping, aircast

CASTS Too tight: swelling, pain, coolness, change in color of distal skin parts; bivalve the cast and inspect the skin; think of compartment syndrome, infection,

THERMAL THERAPY Cryotherapy Vasoconstriction, limiting blood flow, decreasing hemorrhage and edeam, decreased metabolic requirement, less histamine and inflammatory mediator release Contraindications: cold allergy, Raynauds phenomenon Relative contraindications: RA, paroxysmal cold hemoglobinuria Four stages of senstation cold sensation for 1-3 min burning or aching sensation for 2-7 min local numbness and aneshtesia from 5-12min reflex deep vasodilation without a correspoding increase in metabolism (similar to rewarming shock) at 12-15 min THUS: maximum of 15 min recommended, must endure the burning/aching phase to achieve benefit Heat Increased blood flow, metabolic demands May feel better but doesnt help acute injury