Extremity Hematoma: When to consider imaging studies and admission

Authors: Jorge Morales, DO (EM Resident Physician, Western Michigan University Homer Stryker, MD School of Medicine) and Michael Williams, MD (EM Attending Physician, Kalamazoo Emergency Associates, Clinical Faculty, Western Michigan University Homer Stryker, MD School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Definition:

Hematomas are abnormal collections of blood outside of a blood vessel. Damage to the wall of the vessel causes leakage of blood into tissues that can be irritating and cause pain, tenderness, and swelling. Most small hematomas can resolve through the coagulation cascade, while larger injuries, particularly those under high pressure such as larger arteries, can continue to bleed.¹

Hematomas can originate from muscle tissue either with a direct, blunt impact, indirectly from stretching or tearing of muscle, or spontaneously. Risk factors that could contribute to spontaneous muscle contusions include anticoagulant therapy (especially in the elderly), intense non-contact exercise, hemophilia, hypertension, and following total hip arthroplasty.²

Myositis ossificans is the formation of bone tissue within the muscle, most commonly occurring after traumatic injury to the specific area. It most commonly occurs in large muscle groups and is typically benign.

Treatment for hematoma typically includes the following for conservative therapy:

• Rest (immobility), cold compression, elevation, NSAIDS (no steroids) for first 24-48 hours depending on severity. All are thought to reduce blood flow to the injured area.^5,9,1
• For quadriceps contusions: immobilize knee in 120 degrees of flexion for first 24 hours^3,8,9
• After 3-5 days, begin the active phase which includes pain-free muscle stretching, strengthening, range of motion, weight bearing, maintenance of aerobic fitness, proprioceptive exercises, and functional training.^5,6,9
• For quadriceps contusions, consider imaging if unable to perform painless full range of motion after 3-4 weeks of conservative therapy to evaluate for conditions such as Myositis Ossificans, intramuscular hematoma or seroma, osteomyelitis.⁹

Role of Laboratory studies:

• In most cases, extensive laboratory workup is unnecessary.³
• Consider obtaining a CBC and coagulation studies in cases with massive bleeding or in a patient with a bleeding disorder.³
• Consider obtaining a serum CK level and urinalysis if there is extensive bruising and rhabdomyolysis is a concern.³

Role of Imaging Studies:

Imaging is usually not indicated if mild bruising is present and muscle function is intact.

Plain Radiograph Indications:

• Failure of conservative management.⁴
• Large contusion with concern for underlying bone abnormality.
• Differentiate between soft tissue and bone abnormalities (fracture, bone tumor, Myositis Ossificans).⁵
• Soft tissue calcifications suggestive of Myositis Ossificans take up to 6 weeks to appear on plain film (may occur within 3 weeks).⁴

Musculoskeletal Ultrasound (US) Indications:  

• US has several important potential advantages over magnetic resonance imaging (MRI), such as superior spatial resolution, cost, convenience, portability, and dynamic evaluation of the injury.⁶
• Based on a study by Megliola et al. that compares US and MRI, US appears to be an equivalent method of identifying muscle contusion injury.⁶
• Has the advantage of allowing aspiration of hematoma and serial evaluation.⁶
• Highly operator dependent and requires a skilled and experienced clinician.⁵
• Within first 24 hours, hematoma can appear hypo- and hyper echoic. In the following days, it will appear hypo echoic or anechoic until coagulation has occurred, giving an inhomogeneous appearance.⁶
• Useful for evaluating location and extent of hematoma⁷
• Detect the presence of complications such as muscle tears or Myositis Ossificans (early signs of calcification show up more quickly on US than other imaging).⁷
• Small, limited studies show lower false positive rate for complete quadriceps or patellar tendon ruptures when compared to MRI and better specificity for detecting patellar tendinopathy.⁷

Soft Tissue MRI Indications:

• Failure of conservative therapy
• Poor quality US images or experienced musculoskeletal ultrasonographer not available.⁷
• When surgery is indicated, MRI may be valuable preoperatively (allow surgeon to make this determination).⁷

 MRI Note: If the history, physical examination, and US findings indicate a complete tendon tear, MRI is generally not necessary.⁷

Vascular Studies:

• Obtain Ankle Brachial-Indices (ABIs) +/- Doppler Arterial Ultrasound if hemodynamically stable and concern for vascular injury present.¹¹
• If hard signs are present for vascular injury, the patient should be taken emergently to the OR.
• Consider CT angiogram of affected extremity if equivocal pulse examination, abnormal ABI despite adequate resuscitation, or high-risk mechanism i.e posterior knee extension.¹²
• Consult vascular surgeon for immediate operative intervention if signs of vascular injury are present and the patient is hemodynamically unstable. Hard signs are less reliable in blunt trauma compared to penetrating.^11,12

Compartment pressures: Obtain compartment pressures using Stryker intra-compartment pressure monitor if clinical suspicion for compartment syndrome.⁴  Most common precipitants include fracture (particularly tibial), crush injuries, or arterial injuries.²

When to Consider Admission:

1) Potential indication for emergent surgical evacuation:

• Compartment syndrome^{2,3, 10}
• Concern for infected hematoma (cellulitis, abscess, myonecrosis, necrotizing deep tissue infection)²
• Neurovascular impingement suggestive on exam²
• Arterial vascular injury demonstrating by clinical and imaging findings⁹
• Concomitant open fracture or penetrating traumatic injury⁹
• Overlying skin necrosis¹¹

2) Rhabdomyolysis²

3) Anticoagulant reversal indicated for clinically significant bleeding such as compartment syndrome or life-threatening bleeding:¹²

• Speed and extent of reversal should be balanced against the risk of recurrent thromboembolism in patients. For example, a patient anticoagulated for a prosthetic mitral valve has a high risk for potential thrombosis/embolization if rapidly reversed.¹²
• Specialist consultation advised for guidance with decision making.¹²

*Specific reversal agents for various antithrombotic/anticoagulant agents:

– Administer oral activated charcoal for agent if patient is able to protect their airway and the last anticoagulant dose was taken within the previous 2 hours.^12,13

– 4-Factor Prothrombin Complex Concentrates (PCC) for direct oral anticoagulants (DOACs), except Pradaxa, for which Idarucizumab (Praxbind) is given. Also consider hemodialysis for removal of Pradaxa.¹²

– Andexanet alfa (Factor Xa inhibitor antidote) or universal DOAC antidotes such as Ciraparantag and FXa are currently under investigation and not yet available for clinical use.^12,13

– Warfarin: Give IV Vitamin K 5-10 mg slow bolus for Warfarin with 4-Factor PCC (weight-based dosing depends on INR) or FFP.¹³

– Heparin: immediate cessation and observation for serial aPTT if minor bleeding, Protamine Sulfate for major bleeding.¹³

– Fondaparinux: For life-threatening bleeding, anecdotal evidence suggests rFVIIa is effective.¹³

– Antiplatelet agents (i.e. Aspirin, Clopidogrel, Prasugrel, Ticagrelor): IV Desmopressin 30-40 mcg/kg over 30 minutes, Platelet transfusion to increase count by 50,000/mm3¹⁵

– Fibrinolytics: Fibrinogen concentrate or Cryoprecipitate if Fibrinogen level <100 mg/dL. May repeat dose (70 mg/kg IV) if level remains <100.^16,17  Two U of FFP if bleeding persists and fibrinogen level >100 mg/dL. If bleeding continues after FFP, give antifibrinolytic agent such as Aminocaproic acid 5 mg IV over 60 minutes followed by 1 gram/hour continuous IV infusion for 8 hours or until bleeding stops, or Tranexamic acid (TXA)10 mg/kg IV every 6–8 hours.¹⁶ One source (UpToDate) recommended administering an antifibrinolytic agent in all cases of major, life-threatening bleeding while on anticoagulant therapy. Oral dosing used for TXA is 1-1.5 g every 8-12 hours for the duration of major bleeding. For IV dosing (preferred), they use a 10-20 mg/kg bolus every 6-8 hours.¹⁵

Case #1:

CC: Left calf pain, swelling and bruising.

HPI: 22 year-old male local college football player with no significant past medical history who presents to your ED with complaint of left calf pain, swelling and bruising for the past 2 hours after being accidentally struck by another player’s helmet. The pain significantly worsens with any weight bearing onto his left leg or movement of his foot. He denies numbness, tingling or pain to other areas including to his left knee, ankle and hip. ROS is otherwise negative.

Physical Exam: T 98.9 BP 143/87 HR 112 RR 14 SpO2 98% on RA.

Pertinent Positives:

• Moderate amount of non-pitting edema to upper half of left posterior calf with underlying ecchymosis measuring about 6 x 8 cm.
• Significant tenderness with light pressure applied over left calf diffusely.
• Limited and exquisitely painful passive ROM with left foot plantar flexion and dorsiflexion with 4/5 strength.

Pertinent Negatives:

• No open wounds or gross deformities
• No ecchymosis, edema or deformity over the Achilles tendon. Negative Thompson’s test.
• 2+ DP and PT pulses bilaterally
• Toes are warm to touch with no pallor or cyanosis
• Sensation intact to light touch along left L4-S1 distributions

What is your next step in management of this patient?

Answer: This presentation should raise suspicion for developing compartment syndrome (pain out of proportion to exam findings). Evaluate pressures in left superior and deep posterior leg compartments and consult orthopedic surgery. Fasciotomy may be required.

Case #2:

CC: 2 months of right thigh pain and weakness

HPI: 45 year old female with 2 months of mild-to-moderate, persistent right thigh pain and weakness not improving with conservative measures including R.I.C.E., NSAIDs and 2 physical therapy sessions. Symptoms began after accidently falling off of her bicycle. She initiated noted bruising to her thigh but no open wounds. An X-ray of her right femur performed 2 weeks after the injury revealed moderate soft tissue swelling along her anterolateral region adjacent to the mid femoral shaft but no acute or sub acute femoral fractures or radiopaque foreign bodies. Despite some improvement in her pain level, she notes her right thigh muscle strength has not fully recovered and continues to walk with a slight limp.

ROS: Pertinent negatives include no fevers, chills, night sweats, unintentional weight loss, numbness, tingling, pallor or cyanosis to lower extremities, knee or hip pain or swelling.

PMH: Diabetes Mellitus Type 2, Fibromyalgia, Depression, and Generalized Anxiety Disorder

PSH: C-section x 2

Medications: Metformin, Gabapentin, Prozac, Xanax, Motrin, Tylenol

Physical Exam: T 98.8  BP 136/84  HR 85 RR 12 SpO2 97% on RA

Pertinent positives on PE:

• Faint, residual ecchymosis over her right anterolateral mid-thigh with a firm, subcutaneous mass with poorly-defined borders that is tender to touch.
• Mild pain and weakness with right knee extension

Pertinent Negatives on PE:

• No skin maceration, palpable fluctuance, crepitus or bullae
• Sensation intact to light touch along right L1-S2 distributions
• Full active and passive ROM to right hip and knee flexion and extension

What is the next step in management?

Answer: The next step is to order a right femur X-ray to evaluate for the presence of soft tissue calcifications suggestive of Myositis Ossificans. This appearance takes about 6 weeks to appear on plain films and would not have been expected on the X-ray taken 2 weeks after the injury. If unremarkable, proceed to soft-tissue thigh MRI given failure of conservative management.

Pearls:

-Most extremity hematomas can be managed conservatively without the need for imaging studies.

-Consider imaging if the patient is not improving as expected or concerned for other complicating injury such as fracture, tumor, or arterial vascular injury. Musculoskeletal ultrasound has been found to be a useful tool in evaluating hematomas, muscle contusions and other muscle injuries but is operator dependent. Soft tissue MRI generally not indicated in the ED setting.

-Myositis ossificans takes approximately 6 weeks to be visualized on plain film.

-Have a low threshold to evaluate for developing compartment syndrome if suspicious based on clinical findings.

-Know potential indications for emergent surgical evacuation and admission.

-Antithrombotic/anticoagulant reversal generally not indicated unless compartment syndrome or hemodynamic instability. Specialist consultation advised to assist with risk/benefit assessment.

References / Further Reading:

1. Wedro, MD, Benjamin. “Hematoma.” http://www.medicinenet.com/hematoma/page2.htm. Reviewed on 11/4/2016.
2. Ramos, Leonardo Addeo, Texeira de Carvalho, Rogerio, Abdalla, Rene Jorge, McNeill Ingham, Sheila Jean (2015). Surgical Treatment of Muscle Injuries. Current Reviews in Musculoskeletal Medicine. June, 8(2): 188–192.
3. Herbenick MD, Michael A. Ho MD, Sherwin SW. “Contusions.” http://emedicine.medscape.com/article/88153-overview. Updated October 25th, 2015.
4. Hughes, MD, Michael (http://www.orthobullets.com/sports/3103/quadriceps-contusion
5. Kary, Joel W (2010). Diagnosis and management of Quadriceps Strains and Contusions. Current Reviews of Musculoskeletal Medicine. 3 (1-4): 26-31.
6. Trojian TH. Muscle contusion (thigh). Clinical Sports Medicine. 2013 Apr; 32(2):317-24.
7. Daghi, F, Zacchino, M, Canepari, M, Nuccu, P, Alessandrino, F (2013). Muscle Injuries: Ultrasound Evaluation in the Acute Phase. Journal of Ultrasound. 16(4): 209–214.
8. Von Fange, MD, Timothy J. https://www.uptodate.com/contents/quadriceps-muscle-and-tendon-injuries?source=search_result&search=quadriceps%20contusion&selectedTitle=1~150
9. Garvey, Joanne, De Boitselier, Ellen, Lowe, Rachel, Herteleer, David, Ritchie, Laura “Quadriceps Muscle Contusion.” www.physio-pedia.com/quadriceps_muscle_contusion.
10. Jan van der Woude, Henk & Smithius, Robin. “Sclerotic bone tumors and tumor-like lesions.” http://www.radiologyassistant.nl/en/p4bc9a97980036/sclerotic-bone-tumors-and-tumor-like-lesions.html#in527937796c82c.
11. Cannon MD, FACS, Jeremy W., Rasmussen, MD, FACS, Todd E. Severe Extremity Injury in the Adult Patient. https://www.uptodate.com/contents/severe-extremity-injury-in-the-adult-patient. Last updated February 18th, 2016 (literature review current through April 2017).
12. Sherman, Scott C. Simon’s Emergency Orthopedics, 7th Edition. Chapters 1, 4, 13, 19, 21. The McGraw-Hill Companies, Inc., 2015.
13. Heilman, James (2016). “Trauma to the Extremities.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition: Chapter 266. McGraw-Hill Education. 2016.
14. Pagan, M. & Hunter J. (2011). Lower Leg Haematomas: Potential for Complications in Older People. Wound Practice and Research. 19:1.
15. Garcia, MD, David M & Crowther, MD, MSc, Mark. “Management of bleeding in patients receiving Direct Oral Anticoagulants.” Last updated April 10th, 2017. https://www.uptodate.com/contents/management-of-bleeding-in-patients-receiving-direct-oral-anticoagulants?source=search_result&search=management%20of%20bleeding%20in%20patients%20receiving%20direct%20oral%20anticoagulants&selectedTitle=1~150#H3430364
16. Slattery, David E & Pollack, Jr. Charles V. “Thrombotics and Antithrombotics.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Chapter 239. McGraw-Hill Education. 2016.
17. Coli, Clinton J & Santen, Sally A. “Transfusion Therapy.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Chapter 238. McGraw-Hill Education. 2016.