Soft tissue hematoma is a cavity formed as a result of trauma and filled with blood or clots. Occurs when blood is poured into the tissues from a damaged vessel. It is a dense or fluctuating tumor-like formation, painful on palpation, accompanied by swelling and discoloration of the skin. With a deep location, it is manifested by a violation of the shape and a local increase in the volume of the affected area. Pathology is diagnosed on the basis of complaints, anamnesis and external examination. In doubtful cases, ultrasonography is prescribed. Treatment – local conservative measures, in severe cases, autopsy, drainage is indicated.
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Soft tissue hematoma is a common pathological condition in modern traumatology. It can be detected in the extremities, face or trunk, be small or extensive, located subcutaneously, intramuscularly, subfascially, under the mucous membrane. Small superficial hematomas are more often found in the area of the fingers, extensive blood accumulations – in the area of the lower extremities (lower legs and thighs). Small formations often resolve on their own. When an infection is infected, suppuration is observed. Pathology is diagnosed in all population groups, there is a certain predominance of people with a high level of physical activity (children, young men).
Hematomas can be found in all types of traumatic injuries (road, industrial, falls from a height, etc.), but the most common cause of their formation is a domestic injury. Pathology usually occurs after a direct blow with a bruise, can be formed due to intense compression, rupture of the vessel with fractures, dislocations and other injuries. Predisposing factors that increase the likelihood of developing this condition are diseases accompanied by disorders of the blood coagulation system and increased fragility of the vascular wall.
The mechanism of soft tissue hematoma formation is based on a rupture of a blood vessel without a wound, less often with a small wound (usually a puncture). Intensive local traumatic effects in case of bruising, bone fragment damage, a sharp unnatural displacement of some anatomical structures relative to others in case of fracture or dislocation causes a violation of the integrity of the vascular wall. Blood flows out under pressure and “pushes” the tissues, forming a cavity.
Part of the blood permeates the tissues, therefore, cyclical changes in the color of the skin are observed in the future, due to the disintegration of red blood cells with the formation of hematoidin and hematosiderin. At first, the damage site becomes purple or purplish-bluish, later it acquires a greenish, and then a yellowish tint. With deep hematomas, the skin color may remain unchanged.
Subsequently, the hematoma either resolves or persists for a long time, undergoing a series of successive changes, culminating in scarring. When opening fresh formations, the blood is scarlet, viscous, thick, sometimes jelly-like, which is explained by the activity of coagulation factors. Later, either old clots or dark liquid lysed blood are found in the cavity. When emptying old hematomas, clots can be hard, form a solid mass, poorly separated from surrounding tissues, which is associated with the process of scarring and degeneration into fibrous tissue. Infected cavities are filled with serous or purulent contents.
Systematization is carried out on several grounds. The purpose of the division into groups is to assess the severity of the pathology, the choice of therapeutic tactics, determining the need for surgical intervention and the most likely prognosis. In clinical practice , the following types of hematomas are distinguished:
- By localization. Hematomas can be located under the skin, in the submucosal layer, under the fascia, in the thickness of muscle tissue. The largest cavities are localized inside the muscles or subfascially (between the muscle and fascia), which is due to the rich blood supply and elasticity of skeletal muscles.
- According to the condition of the vessel. Pulsating hematomas are formed when a large-caliber vessel is damaged, they differ in the absence of a blood clot in the area of damage, the possibility of free movement of blood from the formation cavity to the vessel cavity and back. Non-pulsating hematomas are detected when the integrity of small and medium-sized vessels is violated, the defect of the wall of which is quickly closed by a thrombus.
- According to the state of the spilled blood. Non–coagulated (fresh) hematomas are detected in the first hours or days after the injury, coagulated – after a few days, lysed (filled with old blood, unable to coagulate) – after a few weeks. These terms may vary depending on the activity of coagulation factors, the size of the formation and other circumstances. When the infection penetrates, infection is observed, later suppuration.
- In relation to tissues. With the development of diffuse hematomas, the process of tissue impregnation with blood prevails over the process of their “spreading”, the cavity is small or absent. During the formation of limited formations, the tissues are slightly impregnated, the bulk of the spilled blood is in the cavity. Closed hematomas are determined in the long term, characterized by the presence of a layer of dense connective tissue separating the cavity from the surrounding structures.
- By severity. Light hematomas occur about a day after a traumatic excess, more often resolve on their own. Formations of moderate severity are formed within 3-5 hours, require conservative or operational measures. Severe injuries are diagnosed 1-2 hours after the injury, and are an indication for autopsy and drainage.
The first manifestations of pathology are pain and local edema. A characteristic difference between a hematoma and other soft tissue injuries at an early stage is a more pronounced limitation of swelling, the absence of a gradual transition from edematous structures to unchanged ones. In the following hours, the swelling begins to spread. Soreness increases, movements are limited due to pain. Patients complain of a feeling of pressure or tension in the affected area. With a superficial location of the hematoma, the skin becomes bluish-purple. With deep localization of the cavity, local hyperemia of the skin may be detected, sometimes the skin color does not change.
During palpation at the initial stage, fluctuation is usually absent, densification and sharp soreness are determined. After the formation of a limited cavity containing liquid blood, a positive symptom of swelling is detected. At first, the affected area is tense when feeling, after the swelling subsides, the density of tissues may decrease. With a favorable course, the swelling gradually decreases in size and disappears, with an unfavorable course, it persists for a long time, causing pain during movements.
The main possible negative consequence of a soft tissue hematoma is its suppuration with the formation of an abscess. The complication is more often found with concomitant damage to the skin. When infectious agents enter the formation cavity, the pain syndrome increases, local hyperemia and hyperthermia are noted, symptoms of general intoxication are added. In some cases, it is possible to spread the purulent process with the formation of phlegmon or the development of sepsis.
Diagnosis is carried out by a traumatologist. In the absence of signs of bone and joint damage, additional studies are usually not required, the diagnosis is made taking into account the anamnesis data (the presence of a fresh injury with a characteristic mechanism), the patient’s complaints and the results of a physical examination. With deep-seated hematomas, soft tissue ultrasound may be prescribed to assess the severity of the injury and differentiate with a bruise. With concomitant damage to solid structures, radiography of the corresponding segment is performed. In addition to bruising, differential diagnosis sometimes has to be carried out with fractures, tears of ligaments and muscles, less often with positional compression syndrome, acute myositis, ischemia with thrombosis of a vessel of small or medium caliber and some other conditions accompanied by dense local edema.
Treatment is usually carried out on an outpatient basis, the tactics are determined by the severity of the process and the time since the injury. With fresh injuries, the limbs are given an elevated position, cold is applied (a hot water bottle with cold water, ice packs wrapped in a towel), a pressure bandage is applied to reduce bleeding. After the organization of small formations, UHF is prescribed, warm warmers are used to accelerate resorption. Small superficially located hematomas are opened in the emergency room. With large and deep cavities, the appearance of signs of infection, hospitalization in the trauma department, autopsy and drainage against the background of antibiotic therapy is indicated. For uninfected hematomas after autopsy, tight bandaging is recommended to eliminate the cavity and accelerate healing.
Prognosis and prevention
The prognosis is usually favorable. Most hematomas resolve on their own within 2-3 weeks. The average period of disability after opening the cavity is about 2 weeks, the outcome is a complete recovery. In the absence of therapeutic measures, the formation of an array of fibrous tissue (scar) with the formation of an external defect is possible. In the presence of infection, the duration of treatment and prognosis may vary, depending on the severity of the process. Prevention includes the prevention of injuries and early medical attention when injuries are sustained.