Practical Guidelines for the Safe Use of Dimethyl Sulfoxide (DMSO) in Orthopedic Treatment

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Practical Guidelines for the Safe Use of Dimethyl Sulfoxide (DMSO) in Orthopedic Treatment

Introduction

Dimethyl sulfoxide (DMSO) is a multifunctional organosulfur compound that has gained widespread use in medical practice, particularly in orthopedic surgery. Initially discovered in the 19th century as an industrial solvent, DMSO later found medical applications due to its pronounced anti-inflammatory, analgesic, and penetrating properties. These unique characteristics make it an indispensable aid in the treatment of various musculoskeletal disorders. The goal of this guide is to provide a comprehensive analysis of the pharmacodynamics, clinical applications, preparation protocols, and therapeutic regimens of DMSO in orthopedics, particularly in combination with analgesics such as lidocaine.

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Pharmacodynamics and Mechanism of Action

Anti-inflammatory and Analgesic Properties

The anti-inflammatory properties of dimethyl sulfoxide (DMSO) are primarily due to its inhibition of nuclear factor kappa B (NF-κB), a key transcription factor that regulates the expression of numerous pro-inflammatory genes. By suppressing NF-κB activation, DMSO reduces the production of major pro-inflammatory cytokines, such as IL-1, IL-6, and TNF-α. This decrease in cytokine activity helps mitigate tissue inflammation in the musculoskeletal system, promoting healing processes and alleviating symptoms in chronic inflammatory conditions.

The analgesic effects of DMSO are associated with its ability to alter nerve conduction. It decreases the transmission of pain signals in both peripheral and central pathways, providing effective pain control without involving opioid receptors. This mechanism makes DMSO a potent alternative to opioid-based treatments, minimizing the risks of dependency, tolerance, and related side effects while ensuring sustained pain relief.

Penetrative Properties

One of the most significant characteristics of DMSO is its unparalleled ability to penetrate biological membranes. This property makes it an excellent agent for enhancing the absorption and action of co-administered drugs. In orthopedic practice, this capability is invaluable for targeted drug delivery to deeper tissue layers, including muscles, joints, and ligaments, where topical agents typically struggle to reach. DMSO acts as a carrier, facilitating the transdermal absorption of active compounds, increasing their bioavailability, and ensuring effective delivery to sites of inflammation or injury.

Vasodilation and Improved Microcirculation

DMSO induces vasodilation, meaning it expands blood vessels, thereby enhancing local blood flow and facilitating the delivery of oxygen and essential nutrients to affected tissues. Improved microcirculation accelerates the body’s natural healing processes, supporting tissue regeneration and recovery. This vasodilatory effect is particularly beneficial in the treatment of tendinopathies, where increased blood flow can reduce inflammation and stimulate the repair of damaged fibers, as well as in post-surgical cases, where improved circulation aids in reducing swelling and overall healing.

These pharmacodynamic properties make DMSO a valuable adjunctive agent in orthopedic therapy, combining anti-inflammatory, analgesic, and penetrative actions to achieve the best possible treatment outcomes for patients.

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Clinical Application in Orthopedic Surgery

1. Osteoarthritis

Pathophysiology and Rationale

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by progressive loss of articular cartilage, subchondral bone sclerosis, and synovial inflammation. These pathological changes result in chronic pain, stiffness, and functional impairment. The inflammatory cascade in OA involves cytokines, proteolytic enzymes, and oxidative stress, all contributing to cartilage degradation. Dimethyl sulfoxide (DMSO), due to its potent anti-inflammatory, antioxidant, and analgesic properties, offers significant benefits in managing OA symptoms. Its ability to deeply penetrate tissues enhances the bioavailability of co-administered drugs, providing a synergistic effect.

Protocol for Preparing and Applying DMSO Compresses

1. Solution Preparation:
   • Dilute pharmaceutical-grade DMSO (99% purity) with sterile saline or distilled water to create a 25% solution. This concentration ensures efficacy while minimizing the risk of skin irritation.
2. Application Procedure:
   • Skin Preparation: Ensure that the skin over the affected joint is clean and free from creams, oils, or other potential irritants to maximize absorption.
   • Soaking Gauze: Saturate sterile gauze with the prepared 25% DMSO solution. Lightly wring out excess liquid to prevent dripping while maintaining adequate moisture.
   • Placement: Apply the moistened gauze directly over the affected joint, ensuring full coverage of the symptomatic area.
   • Compress Fixation: Cover the gauze with plastic wrap or a plastic sheet to prevent evaporation and enhance absorption. Secure the compress with an elastic bandage, ensuring it is not too tight to avoid compromising circulation.
   • Contact Duration: Leave the compress in place for 20–30 minutes. Exceeding this time may increase the risk of skin irritation or chemical burns.
   • Frequency of Application: Apply the compress once daily, continuing treatment for 7–14 days or as per physician recommendations based on clinical response.
3. Combination with Analgesics for Enhanced Effect:
   • For patients with severe pain, mix 1 part of the 25% DMSO solution with 1 part of a 2% lidocaine solution. Follow the same application protocol. This combination provides immediate and prolonged pain relief, enhancing therapeutic effectiveness during acute pain episodes.

Clinical Case Example

Patient Profile: A 67-year-old woman with moderate to severe knee osteoarthritis characterized by chronic pain (VAS score of 8), morning stiffness lasting over 30 minutes, and restricted mobility. Previous treatment with oral NSAIDs and physiotherapy provided only partial relief.

Treatment Protocol:

• The patient was prescribed daily DMSO compresses at a 25% concentration for 14 days.
• During acute flare-ups, a combination of 25% DMSO solution with 2% lidocaine was applied for rapid pain relief.

Results:

• After 2 weeks, the patient reported a significant reduction in pain (VAS score decreased to 4), improved joint mobility, and increased ability to participate in physical therapy.
• No adverse effects were observed, except for mild warmth on the skin and a temporary garlic-like odor, both of which were well tolerated.

Key Factors for Clinical Success

1. Patient Education:
   • Provide detailed instructions on preparation and application, including proper skin cleansing and compress placement.
   • Discuss potential side effects, such as the garlic-like odor or mild skin warmth, which are typically temporary and well tolerated.
2. Safety Monitoring:
   • Regularly inspect the application site for signs of irritation or allergic reactions.
   • Adjust treatment plans based on patient response and tolerance.
3. Follow-Up Appointments:
   • Schedule follow-up visits to monitor symptoms, adjust treatment frequency, and ensure optimal outcomes.

Conclusion

DMSO compresses offer a safe, effective, and non-invasive adjunctive treatment for osteoarthritis, particularly in cases where conventional therapies provide insufficient relief. By reducing inflammation, alleviating pain, and improving joint function, DMSO enhances the quality of life for OA patients. This protocol, implemented with careful attention to patient needs, serves as a valuable addition to the orthopedic treatment toolkit.

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2. Rheumatoid Arthritis (RA)

Mechanism of Action and Benefits

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by persistent inflammation of the synovial membrane, progressive joint damage, and severe pain. The disease is driven by an excessive immune response leading to the release of pro-inflammatory cytokines such as TNF-α, IL-1, and IL-6, which sustain inflammation and joint destruction. The potent anti-inflammatory properties of DMSO inhibit these cytokines, reducing inflammation and providing symptomatic relief. Additionally, its ability to penetrate tissues enhances the delivery of therapeutic agents, making it a valuable adjunct to systemic RA treatment.

Protocol for Preparation and Application of DMSO Compresses

1. Solution Preparation:
   • Use pharmaceutical-grade DMSO (99% purity), diluted to a 50% concentration.
   • Mix equal parts of DMSO and sterile saline or distilled water. This concentration is optimal for inflammation and pain control while minimizing skin irritation risks.
2. Application Procedure:
   • Skin Preparation: Clean the skin area where the compress will be applied, removing lotions, oils, or other substances.
   • Gauze Soaking: Soak sterile gauze with the 50% DMSO solution, ensuring sufficient moisture without dripping.
   • Compress Application: Place the soaked gauze on the inflamed joint, ensuring full coverage of the affected area.
   • Covering: Cover the gauze with plastic wrap or polyethylene to prevent evaporation and maintain skin contact.
   • Fixation: Secure the compress with an elastic bandage. The bandage should be firm but not restrict circulation.
   • Contact Duration: Keep the compress in place for 20–30 minutes. Do not exceed 30 minutes to avoid skin irritation or chemical burns.
   • Frequency: Apply the compress twice daily, in the morning and evening, for sustained therapeutic effects.
3. Combined Pain Relief:
   • For rapid pain relief during acute episodes, mix equal parts of the 50% DMSO solution and a 1% lidocaine solution.
   • Apply this compress using the same protocol. Lidocaine provides immediate local anesthesia, enhancing overall treatment efficacy.
4. Treatment Duration:
   • Continue compress application for at least four weeks. Regular clinical assessments are necessary to monitor progress and adjust the treatment plan as needed.

Clinical Considerations

1. Monitoring and Safety:
   • Regularly assess the skin condition to detect potential adverse reactions such as irritation or dryness.
   • Perform a patch test before initiating full treatment to check for sensitivity or intolerance.
2. Patient Education:
   • Inform patients that a temporary garlic-like odor or mild warmth on the skin is normal and transient.
   • Emphasize the importance of consistent application to achieve optimal results.
3. Precautions:
   • Use with caution in patients with liver or kidney dysfunction, as DMSO metabolism and excretion may be impaired. Regular monitoring of organ function is recommended.
4. Comprehensive Treatment:
   • Highlight that DMSO compresses are an adjunct therapy to systemic treatments such as disease-modifying anti-rheumatic drugs (DMARDs) and biologic agents, not a replacement.

Clinical Case Example

Patient Profile: A 58-year-old woman with seropositive RA presenting with severe pain in hand and knee joints, morning stiffness lasting over 90 minutes, and significant difficulty performing daily activities. Previous treatment, including DMARDs, provided only partial relief.

Treatment Plan:

• Compresses: Apply 50% DMSO solution twice daily to affected joints.
• Pain Management: Use compresses with a combination of 50% DMSO and 1% lidocaine during flare-ups.
• Duration: Four weeks with follow-up assessments every two weeks.

Outcomes After Four Weeks:

• Pain reduced from 8/10 to 4/10.
• Significant reduction in joint swelling and erythema.
• Morning stiffness decreased to 30 minutes, allowing the patient to regain more independence.
• The only side effect was mild skin dryness, easily managed with a neutral moisturizer.

Conclusion

DMSO compresses in RA treatment provide orthopedic specialists with an effective, non-invasive method to reduce pain and inflammation and improve joint function. When implemented following clinical standards, this protocol contributes to a multidisciplinary approach to RA management.

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3. Tendinopathies and Ligament Sprains in Adults

Mechanism of Action and Rationale

Tendinopathies and ligament sprains are common orthopedic conditions that cause pain, inflammation, and functional limitations. These injuries involve microtears of tendon or ligament fibers, inflammatory responses, and associated pain. DMSO’s anti-inflammatory properties, its ability to penetrate deep tissues, and its enhancement of co-administered drug absorption make it an effective adjunct in treating these conditions. By reducing inflammation, relieving pain, and promoting tissue repair, DMSO accelerates recovery and improves functional outcomes.

Protocol for Preparation and Application of DMSO Compresses

1. Solution Preparation:
   • Use pharmaceutical-grade DMSO (99% purity), diluted to a 50%–70% concentration, depending on the severity of the condition and skin tolerance.
   • For mild cases or sensitive skin, prepare a 50% solution by mixing equal parts of DMSO and sterile saline or distilled water. For severe cases requiring deeper penetration, use a 70% solution with close monitoring.
2. Application Procedure:
   • Skin Preparation: Thoroughly clean the affected area to remove lotions, oils, or contaminants that may interfere with absorption.
   • Gauze Soaking: Saturate sterile gauze or a cotton pad with the prepared DMSO solution. Ensure adequate moisture without dripping.
   • Compress Application: Place the soaked gauze over the affected tendon or ligament, ensuring full coverage.
   • Fixation: Cover the gauze with plastic wrap or polyethylene to prevent evaporation and secure it with an elastic bandage, ensuring circulation is not compromised.
   • Contact Duration: Keep the compress on for 20–30 minutes. Avoid exceeding this duration to prevent skin irritation or chemical burns.
   • Frequency: Apply the compress 2–3 times daily for sustained therapeutic effects.
3. Combination with Analgesics:
   • For severe pain, mix DMSO with an analgesic such as lidocaine. Prepare a solution by mixing one part 50% DMSO solution with one part 2% lidocaine solution.
   • Apply this combination compress following the same protocol for immediate pain relief and enhanced anti-inflammatory effects.
4. Treatment Duration:
   • Continue treatment for 2–4 weeks based on severity and patient response. Adjustments should be made based on regular clinical assessments and patient feedback.

Clinical Considerations

1. Monitoring and Safety:
   • Conduct periodic evaluations to assess progress, pain reduction, and potential skin reactions.
   • Perform a patch test before initiating full treatment to rule out hypersensitivity or intolerance.
2. Patient Education:
   • Emphasize adherence to the treatment schedule for optimal results. Patients may notice initial relief within the first week, but full recovery typically requires consistent application for several weeks.
   • Inform patients of potential mild side effects such as a warm sensation or transient garlic-like odor, which are normal and harmless.
3. Precautions:
   • Avoid applying DMSO near mucous membranes or on damaged skin.
   • Use cautiously in patients with liver or kidney dysfunction; regular organ function monitoring is recommended.

Conclusion

DMSO compresses provide a practical, effective, and non-invasive treatment option for tendinopathies and ligament sprains. By reducing inflammation, promoting tissue repair, and providing rapid pain relief, this protocol accelerates recovery and enhances functional outcomes. Tailoring treatment to individual patient needs ensures optimal results with minimal risks, making DMSO a valuable tool in orthopedic practice.

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Tendinopathies and Ligament Strains in Children

Mechanism of Action and Justification

Tendinopathies and ligament strains in children typically occur as a result of sports injuries or excessive loading, leading to microtrauma, localized inflammation, and pain. These conditions can significantly limit mobility and interfere with daily activities. DMSO, due to its potent anti-inflammatory properties and ability to penetrate deep tissues, provides targeted symptom relief while enhancing the effectiveness of accompanying medications. Individualizing the DMSO application protocol for children based on age and tolerance ensures safe and effective treatment.

Protocols by Age Groups

1. Toddlers and Preschoolers (1–5 Years)
   1. Solution Preparation:
      • Use a 10%–20% DMSO solution to minimize the risk of skin irritation.
      • To prepare, mix 1 part of pharmaceutical-grade DMSO (99% purity) with 9 parts (10%) or 4 parts (20%) of distilled water or saline solution.
   2. Application Procedure:
      • Skin Preparation: Clean and dry the skin at the site of application.
      • Soaking the Gauze: Saturate sterile gauze or a cotton pad with the solution and gently wring out any excess liquid.
      • Placing the Compress: Position the gauze on the affected area.
      • Securing the Compress:
        • Cover the gauze with plastic wrap to prevent evaporation.
        • Secure the compress with a soft elastic bandage, avoiding excessive pressure.
      • Duration of Contact: Keep the compress on for 10–15 minutes. Exceeding this time is undesirable due to the risk of irritation.
      • Application Frequency: Apply once a day.
   3. Treatment Duration:
      • Continue for 7–10 days, depending on the severity of symptoms and clinical response.
2. Schoolchildren (6–12 Years)
   1. Solution Preparation:
      • Use a 20%–30% DMSO solution for effective control of inflammation and pain.
      • Mix 2–3 parts of DMSO with 8–7 parts of saline solution or distilled water.
   2. Application Procedure:
      • Follow the same skin preparation, gauze placement, and fixation protocol as for younger children.
      • Duration of Contact: Keep the compress on for 15–20 minutes.
      • Application Frequency: Apply the compress once or twice a day, depending on symptom severity.
   3. Treatment Duration:
      • Continue for 10–14 days, with regular assessment of symptom relief and tolerance.
3. Teenagers (13–17 Years)
   1. Solution Preparation:
      • Use a 30%–50% DMSO solution, depending on skin tolerance and the severity of the condition.
      • Mix 3–5 parts of DMSO with 7–5 parts of saline solution or distilled water.
   2. Application Procedure:
      • Follow the adult protocol with the following modifications:
        • Duration of Contact: Keep the compress on for 20–30 minutes.
        • Application Frequency: Apply the compress 2–3 times a day.
   3. Treatment Duration:
      • Continue for 2–3 weeks, adjusting based on the patient’s progress.

Combining DMSO with Analgesics (All Age Groups)

• Formula: Mix 1 part of the prepared DMSO solution with 1 part of a 1% lidocaine solution.
• Application: Follow the same compress protocol, ensuring age-appropriate exposure times and concentrations.

Clinical Aspects

1. Monitoring and Safety:
   • Before full application, perform a patch test to detect potential allergic reactions.
   • Monitor the skin for redness or irritation during follow-up visits.
2. Parental Education:
   • Explain the correct technique for applying the compresses and the importance of adhering to the treatment schedule.
   • Warn about possible side effects, such as a temporary garlic-like odor or mild warmth on the skin, which are not dangerous.
3. Precautions:
   • Avoid using DMSO near mucous membranes or on damaged skin.
   • If there are concerns regarding liver or kidney function, conduct appropriate monitoring.

Clinical Case

Patient Profile: A 10-year-old boy with a Grade I ankle ligament strain following a soccer game. Complaints of swelling, tenderness, and difficulty bearing weight on the affected leg.

Treatment Plan:

• Solution: A 20% DMSO solution was prepared.
• Application: Compresses were applied once daily for 14 days for 15–20 minutes.
• Analgesia: In the first few days, the DMSO solution was combined with 1% lidocaine for pain relief.

Results:

• Short-Term Relief: On day four, swelling and tenderness significantly decreased, and the patient was able to walk with minimal discomfort.
• Complete Recovery: After 14 days, the boy returned to normal physical activity without residual symptoms. No side effects were reported.

Conclusion

DMSO compresses, tailored for pediatric patients, provide a safe and effective treatment method for tendinopathies and ligament strains. By reducing inflammation, alleviating pain, and promoting tissue healing, DMSO supports rapid recovery and functional restoration. Using an individualized approach based on age ensures optimal results with minimal risks, making DMSO a valuable tool in pediatric orthopedics.

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4. Bruises and Hematomas in Adults

Mechanism of Action and Rationale

Bruises and hematomas result from localized injuries that cause rupture of blood vessels and accumulation of blood and fluid in soft tissues. These conditions are typically accompanied by swelling, pain, and skin discoloration, which limits mobility and functionality. Due to its anti-inflammatory, analgesic, and penetrative properties, DMSO accelerates the absorption of hematomas, reduces swelling, and alleviates discomfort. Its ability to improve microcirculation also promotes rapid tissue recovery.

DMSO Compress Preparation and Application Protocol

1. Solution Preparation:
   • Use pharmaceutical-grade DMSO (99% purity), diluted to a concentration of 50%.
   • To prepare a 50% solution, mix equal parts of DMSO and distilled water or sterile saline solution. This concentration provides effective anti-inflammatory action with minimal risks.
2. Application Procedure:
   • Skin Preparation: Clean the affected area thoroughly, removing lotions, oils, or other irritants.
   • Soaking the Gauze: Soak sterile gauze or a cotton pad with the prepared DMSO solution, ensuring adequate moisture.
   • Applying the Compress: Place the soaked gauze directly on the bruise or hematoma.
   • Fixing the Compress:
     • Cover the gauze with polyethylene film or plastic wrap to prevent evaporation.
     • Secure the compress with a soft elastic bandage, avoiding excessive pressure.
   • Duration of Contact: Keep the compress on for 20–30 minutes. Prolonged exposure may cause skin irritation.
   • Frequency of Application: Apply the compress twice a day for optimal results.
3. Combination with Analgesics:
   • For patients with severe pain, mix 50% DMSO solution with 2% lidocaine solution in equal parts.
   • Use this combination according to the same compress protocol for rapid pain relief.
4. Treatment Duration:
   • Continue treatment for 7–14 days, depending on the severity of the condition and the patient’s response.
   • Regularly assess progress and adjust the treatment plan as necessary.

Clinical Example

Patient Profile: A 45-year-old male with a thigh bruise from a football game, causing significant swelling, skin discoloration, and pain rated 7/10 on the VAS scale. The patient complained of difficulty walking due to discomfort and stiffness in the affected limb.

Treatment Protocol:

• Compresses: A 50% DMSO solution was applied with sterile gauze twice a day.
• Pain Relief: During severe pain episodes, a combination of 50% DMSO and 2% lidocaine was used.
• Duration: Each compress was kept on for 30 minutes, and treatment lasted for 10 days.

Results:

• Day 3: Swelling began to decrease, and the patient reported improved comfort, with pain reduced to 5/10.
• Day 7: Significant improvement in mobility, pain decreased to 3/10, and the hematoma began to resolve.
• Day 10: The hematoma nearly disappeared, and the patient returned to normal activities without discomfort.

Conclusions:

• Effectiveness: DMSO compresses provided rapid reduction of inflammation, swelling, and pain, accelerating the recovery process.
• Safety: The patient reported no skin irritation or other side effects, except for a mild garlic-like odor.
• Comfort Improvement: The use of lidocaine combined with DMSO enhanced pain relief during acute pain periods.

Conclusion

DMSO compresses are a powerful tool in the treatment of bruises and hematomas. They reduce swelling, accelerate hematoma absorption, and provide quick pain relief. With an individualized approach to patients, regular monitoring, and protocol adjustments, DMSO becomes an essential instrument in the orthopedic arsenal.

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Bruises and Hematomas in Children

Mechanism of Action and Rationale

In children, bruises and hematomas often occur from falls, sports injuries, or accidental impacts. These conditions are accompanied by the rupture of blood vessels, leading to swelling, pain, and skin discoloration at the site of injury. Thanks to its anti-inflammatory, analgesic, and penetrative properties, DMSO reduces swelling, accelerates hematoma absorption, and alleviates pain, promoting quick recovery.

Protocols by Age Group

1. Infants and Toddlers (1–5 Years)
   1. Solution Preparation:
      • Use a 10%–20% DMSO solution to avoid irritation of delicate children’s skin.
      • To prepare, mix 1 part DMSO with 9 parts (10%) or 4 parts (20%) distilled water or saline solution.
   2. Application Procedure:
      • Skin Preparation: Clean the affected area of skin thoroughly and dry it.
      • Soaking the Gauze: Soak sterile gauze with the solution and gently wring out excess fluid.
      • Applying the Compress: Place the gauze on the affected area.
      • Fixing the Compress:
        • Cover the gauze with plastic wrap or polyethylene to prevent evaporation.
        • Secure with a soft elastic bandage, avoiding tight compression.
      • Duration of Contact: Keep the compress on for 10–15 minutes.
      • Frequency of Application: Apply once a day.
   3. Treatment Duration:
      • Continue treatment for 5–7 days, depending on the severity of the condition and progress.
2. School-Aged Children (6–12 Years)
   1. Solution Preparation:
      • Use a 20%–30% DMSO solution for effective results.
      • Mix 2–3 parts DMSO with 8–7 parts saline solution or distilled water.
   2. Application Procedure:
      • Follow the same steps for skin preparation, soaking the gauze, and fixing the compress.
      • Duration of Contact: Keep the compress on for 15–20 minutes.
      • Frequency of Application: Apply once or twice a day depending on symptom severity.
   3. Treatment Duration:
      • Continue treatment for 7–10 days, with regular assessment of results and tolerance.
3. Adolescents (13–17 Years)
   1. Solution Preparation:
      • Use a 30%–50% DMSO solution depending on skin tolerance and the severity of the bruise or hematoma.
      • To prepare, mix 3–5 parts DMSO with 7–5 parts saline solution or distilled water.
   2. Application Procedure:
      • Follow the adult protocol with the following adjustments:
        • Duration of Contact: Keep the compress on for 20–30 minutes.
        • Frequency of Application: Apply the compress twice a day.
   3. Treatment Duration:
      • Continue treatment for 7–14 days, based on the patient’s condition.

Combination of DMSO with Analgesics (All Age Groups)

• Formula: Mix 1 part prepared DMSO solution with 1 part 1% lidocaine solution.
• Application: Follow the compress protocol, ensuring age-appropriate concentration and exposure time.

Clinical Example: 8-Year-Old Boy with Knee Hematoma

Complaints: The patient suffered a knee bruise during a football game. Swelling, skin discoloration, and pain (VAS 5/10) significantly limited mobility.

Treatment Plan:

• Solution: A 20% DMSO solution was prepared.
• Compresses: Compresses were applied once a day for 15–20 minutes.
• Pain Relief: In the first three days, a combined solution of DMSO and 1% lidocaine was used.

Results:

• Day 3: Significant reduction in swelling, pain decreased to 2/10.
• Day 7: The hematoma almost resolved, and mobility was restored.
• Day 10: Full recovery, and the child returned to normal activities.

Conclusion

DMSO compresses are an effective and safe treatment for bruises and hematomas in children when age-specific protocols are followed. Thanks to their anti-inflammatory and analgesic properties, DMSO supports rapid recovery, alleviating pain and reducing swelling. Careful adherence to protocols and regular monitoring ensures successful outcomes with minimal risks for pediatric patients.

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5. Postoperative Pain and Swelling Management in Adults

Mechanism of Action and Justification

Postoperative recovery is often accompanied by pain and localized swelling, which can slow down rehabilitation, limit mobility, and delay overall recovery. Due to its anti-inflammatory, vasodilatory, and analgesic properties, DMSO reduces the levels of pro-inflammatory cytokines, improves microcirculation, and accelerates tissue healing. Its ability to penetrate deeply makes it an effective agent in postoperative care, helping to reduce pain and swelling.

Protocol for Preparing and Applying DMSO Compresses

1. Preparation of the Solution:
   • Use pharmaceutical-grade DMSO (99% purity) diluted to a 25% concentration.
   • To prepare a 25% solution, mix 1 part of DMSO with 3 parts of distilled water or saline solution. This ensures effectiveness and minimizes skin irritation.
2. Application Procedure:
   • Skin Preparation:
     • Clean the area around the surgical site to ensure a dry and clean surface. Avoid applying to open wounds or sutures.
   • Soaking the Gauze:
     • Soak sterile gauze with the prepared solution, gently squeeze out excess liquid to avoid dripping.
   • Applying the Compress:
     • Carefully place the gauze over the affected area, ensuring complete coverage without applying pressure to sensitive tissues.
   • Securing the Compress:
     • Cover the gauze with plastic wrap or sterile dressing to maintain contact.
     • Secure the compress with a soft elastic bandage, ensuring that circulation is not obstructed.
   • Contact Duration:
     • Keep the compress for 20–30 minutes. Prolonged contact may cause skin irritation.
   • Application Frequency:
     • Apply the compress twice daily for sustained therapeutic effect.
3. Combined Therapy to Enhance Analgesia:
   • Formula:
     • To enhance pain relief, mix 25% DMSO solution with 1% lidocaine in equal parts.
   • Application:
     • Use the combined solution following the same compress protocol.
4. Treatment Duration:
   • Start treatment after the surgical wound is closed, typically 48–72 hours post-surgery.
   • Continue for 2–3 weeks or until significant pain and swelling reduction, adjusting according to the patient’s progress.

Professional Aspects

1. Monitoring and Safety:
   • Regularly check the application site for irritation, redness, or dryness. If necessary, reduce the concentration or frequency of application.
   • Perform a patch test before starting treatment to detect any hypersensitivity.
   • Medical staff should wear gloves while preparing and applying the solution.
2. Patient Education:
   • Explain the proper technique for applying the compress, emphasizing the importance of clean skin and avoiding open wounds.
   • Inform the patient about the potential temporary garlic-like odor, which is a normal and harmless side effect of DMSO metabolism.
   • Encourage adherence to the prescribed treatment schedule for optimal results.
3. Precautions:
   • Avoid using DMSO on mucous membranes, open wounds, or damaged skin.
   • Use cautiously in patients with liver or kidney dysfunction due to DMSO metabolism and excretion.

Clinical Example

Patient Profile: A 56-year-old male after total knee joint arthroplasty. The patient complained of significant postoperative pain and swelling, hindering early mobilization and rehabilitation.

Treatment Protocol:

• Compresses:
  • Applied 25% DMSO solution twice a day for 30 minutes, starting 48 hours after surgery.
  • Compresses were placed around the surgical site, avoiding direct contact with the sutures.
• Combination:
  • During episodes of increased pain, DMSO solution was combined with 1% lidocaine.
• Treatment Duration:
  • Treatment lasted 14 days with regular monitoring of the patient’s condition.

Results:

• Day 3:
  • Pain decreased from 7/10 to 5/10, and swelling significantly reduced.
• Day 7:
  • The patient reported improved knee mobility, pain reduced to 3/10, allowing for active physical therapy.
• Day 14:
  • Swelling disappeared, and the patient achieved functional recovery ahead of the planned timeline.

Conclusion

DMSO compresses are an effective method for treating postoperative pain and swelling. They reduce inflammation, improve tissue healing, and promote faster rehabilitation. When following protocols and monitoring patients regularly, DMSO becomes a valuable tool in postoperative care, ensuring quick and safe recovery.

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Postoperative Pain and Swelling Management in Children

Mechanism of Action and Justification

In children, the postoperative period is often accompanied by pain and localized swelling, which can delay rehabilitation and complicate the return to normal activity. Due to its anti-inflammatory, vasodilatory, and analgesic properties, DMSO reduces swelling and pain by lowering pro-inflammatory cytokines, improving microcirculation, and supporting tissue healing. An individualized approach based on age ensures the effectiveness and safety of DMSO use in pediatric practice.

Protocols by Age Group

1. Infants and Preschoolers (1–5 Years)
   1. Preparation of the Solution:
      • Use 10%–15% DMSO solution to avoid irritation of delicate skin.
      • To prepare a 10% solution, mix 1 part DMSO with 9 parts distilled water or saline solution. For a 15% solution, mix 1 part DMSO with 6 parts liquid.
   2. Application Procedure:
      • Skin Preparation:
        • Clean the skin around the surgical site, ensuring it is dry and free of lotion or ointment residues.
      • Soaking the Gauze:
        • Soak sterile gauze with the solution, gently squeeze out excess liquid.
      • Applying the Compress:
        • Gently place the gauze on the affected area, avoiding pressure.
      • Securing the Compress:
        • Cover the gauze with plastic wrap or sterile dressing to prevent evaporation.
        • Secure with a soft bandage, avoiding tightness.
      • Contact Duration:
        • Keep the compress for 10–15 minutes.
      • Application Frequency:
        • Apply the compress once a day, and if well-tolerated, the frequency may be increased to twice daily.
   3. Treatment Duration:
      • Continue treatment for 5–7 days or until significant pain and swelling reduction.
2. School-Age Children (6–12 Years)
   1. Preparation of the Solution:
      • Use 15%–20% DMSO solution for optimal results.
      • For a 15% solution, mix 1 part DMSO with 5 parts liquid. For a 20% solution, mix 1 part DMSO with 4 parts liquid.
   2. Application Procedure:
      • Follow the same steps for skin preparation, soaking the gauze, applying, and securing the compress.
      • Contact Duration:
        • Keep the compress for 15–20 minutes.
      • Application Frequency:
        • Apply the compress once or twice daily.
   3. Treatment Duration:
      • Continue treatment for 7–10 days, with regular check-ups to monitor progress.
3. Teens (13–17 Years)
   1. Preparation of the Solution:
      • Use 20%–25% DMSO solution, depending on tolerance.
      • To prepare, mix 1 part DMSO with 4 parts (20%) or 3 parts (25%) saline solution or distilled water.
   2. Application Procedure:
      • Use the adult protocol with the following adjustments:
        • Contact Duration: Keep the compress for 20–30 minutes.
        • Application Frequency: Apply the compress twice a day.
   3. Treatment Duration:
      • Continue treatment for 2–3 weeks or until complete resolution of swelling and pain.

Combined Therapy with Analgesics

• Formula:
  • To enhance analgesic effect, mix DMSO with 1% lidocaine solution in equal parts.
• Application:
  • Use following the same compress protocol, taking age-specific exposure time into account.

Clinical Example: 8-Year-Old Girl After Appendectomy

Complaints: The child experienced significant swelling and pain around the surgical site, limiting activity and causing discomfort.

Treatment Protocol:

• Solution: Applied 15% DMSO solution.
• Compresses: Applied gauze soaked with the solution to the surgical area once a day for 15 minutes.
• Pain Relief: On days with increased pain, added lidocaine in a 1:1 ratio.

Results:

• Day 3:
  • Swelling significantly reduced, pain decreased, the child began moving more actively.
• Day 7:
  • Pain completely resolved, swelling greatly reduced, and the child returned to normal activity.

Conclusion

DMSO compresses are an effective method for managing postoperative pain and swelling in children. The individualized approach with appropriate concentrations and treatment duration ensures optimal results and minimizes risks. The use of DMSO in pediatric orthopedics promotes rapid recovery and enhances the quality of life for young patients.

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Practical Protocols for the Preparation and Application of DMSO in Orthopedics

Preparation of DMSO Solutions

For effective and safe use in orthopedic practice, it is important to prepare DMSO solutions at the appropriate concentration, tailored to the specific clinical needs of patients. The following recommendations will help you properly prepare the solutions:

• Base Solution: Use only pharmaceutical-grade DMSO (99% purity) to ensure maximum safety and effectiveness.
• Dilution Recommendations:
  • 10% Solution: Mix 1 part of DMSO with 9 parts of saline solution or distilled water. Ideal for application on sensitive skin areas or for treating mild conditions.
  • 25% Solution: Mix 1 part of DMSO with 3 parts of saline solution or water. Used for the treatment of osteoarthritis or moderate inflammatory pain.
  • 50% Solution: Mix DMSO and saline solution in equal parts. This solution is suitable for more pronounced conditions, such as rheumatoid arthritis or significant soft tissue injuries.
  • 70% Solution: Mix 7 parts of DMSO with 3 parts of saline solution. Provides deep tissue penetration but should be used cautiously on intact skin to avoid irritation.

Combined Dilution with Lidocaine for Enhanced Analgesia

Combining DMSO with local anesthetics, such as lidocaine, enhances the analgesic effect by delivering the anesthetic into deeper tissues.

• Combination of 25% DMSO with Lidocaine:
  • Preparation: Mix 1 part of 25% DMSO solution with 1 part of 2% lidocaine.
  • Indications: Suitable for analgesia in osteoarthritis, postoperative care, and minor injuries.
• Combination of 50% DMSO with Lidocaine:
  • Preparation: Mix 1 part of 50% DMSO solution with 1 part of 1% lidocaine.
  • Indications: Used for more intensive treatment, especially for severe tendinopathies, ligament strains, or significant inflammatory processes.

Application Recommendations

To achieve maximum therapeutic effect and minimize side effects, follow these protocols:

1. Skin Preparation: Clean the skin area and remove any oils or lotions to ensure maximum absorption of the solution.
2. Application Method: Use sterile gauze, cotton pads, or clean gloves to apply the solution evenly to the affected area.
3. Duration of Contact: Leave the solution on the skin for 20–30 minutes to ensure deep penetration.
4. Frequency of Application: Apply DMSO 2–3 times a day, depending on the severity of the condition and patient response.
5. Safety Measures:
   • Always wear gloves when working with DMSO to avoid absorption through the skin.
   • Do not use occlusive dressings without a doctor’s recommendation, as this may increase absorption.
   • Inform patients about possible side effects, such as mild irritation or a garlic-like odor, which disappears after DMSO metabolism.

Monitoring and Treatment Adjustment

Initial Sensitivity Testing Before starting treatment, perform a patch test by applying a small amount of the solution to a skin area. Monitor the reaction for 24 hours to ensure no allergy or irritation develops.

Patient Education Provide detailed instructions on the application technique, expected results, and possible side effects. Emphasize the importance of adhering to the treatment schedule.

Ongoing Evaluation Regularly assess the effectiveness of the treatment, noting changes in pain levels, mobility, and joint function. Adjust the solution concentration or application frequency if necessary.

Precautions and Patient Counseling

Side Effects Although DMSO is generally well tolerated, some patients may experience temporary side effects:

• Mild Reactions: Dryness, irritation, or mild burning sensation on the skin. If these occur, reduce the solution concentration or application frequency.
• Garlic-like Odor: The appearance of the odor is a normal result of DMSO metabolism and requires no treatment.

Contraindications

• Hypersensitivity: Patients with known DMSO allergies should not use the product.
• Liver or Kidney Dysfunction: Due to DMSO metabolism, such patients require careful monitoring. In severe cases, treatment should be avoided.

Pregnancy and Lactation The safety of DMSO during pregnancy and lactation has not been established, so its use should be avoided unless absolutely necessary.

Conclusion

Dimethyl sulfoxide is a versatile agent in orthopedics due to its anti-inflammatory, analgesic, and transport properties. Proper preparation, application, and monitoring of DMSO solutions ensure effective treatment of various conditions such as osteoarthritis, tendinopathies, soft tissue injuries, and postoperative pain. An individualized approach to each patient, education, and regular monitoring allow for optimal results while minimizing risks.

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References:

1. Clinical Experience and Case Series • John, H. & Laudahn, G. (1967). Clinical experiences with the topical application of DMSO in orthopedic diseases: evaluation of 4180 cases. Annals of the New York Academy of Sciences. PubMed

2. Early Review Articles • Demos, C. H., Beckloff, G. L., Donin, M. N., & Oliver, P. M. (1967). Dimethyl sulfoxide in musculoskeletal disorders. Annals of the New York Academy of Sciences. PubMed

3. Comprehensive Pharmacologic Review • Brayton, C. F. (1986). Dimethyl Sulfoxide (DMSO): A Review. Cornell Veterinarian. PubMed
   

4. DMSO as a Vehicle for Enhanced Drug Delivery • Dimethyl Sulfoxide as a Vehicle for Corticosteroids. JAMA Dermatology. JAMA Network

5. Regulatory and Formulation Perspectives • McKim, A. S. & Strub, R. (2008). Dimethyl Sulfoxide USP, PhEur in Approved Pharmaceutical Products and Medical Devices. Pharmaceutical Technology. PharmTech

6. Additional Resource • RxList – DMSO: Health Benefits, Side Effects, Uses, Dose, and More

Prepared by:

Dr. Vasyl M. Shlemko, Orthopedic Surgeon