Muscle hematoma
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- Localization. Trunk and extremities
- Erythematous lesion? Non-erythematous lesion
- Evolution time. Acute: less than 2 weeks
- Skin lesion. Subcutaneous/deep: swelling
- Surface texture. Normal/smooth
- Edges Poorly defined
- Color. Due to blood: pink, red, purple or purple
- Distribution of lesions. Discreet/isolated injury: 1 to 5 injuries
- Associated symptoms. Pain
- Additional information.
Brief information
- Collection of extravasated blood in a muscle group. They can be classified into:
- Superficial intramuscular hematoma
- Deep intramuscular hematoma
- Intermuscular hematoma
- Hematoma with mixed characteristics (intramuscular and intermuscular)
- The clinical diagnosis of a superficial or intermuscular hematoma is generally easy due to the typical manifestation of a flat lesion (macule or stain), with ill-defined limits and an initially pink color that progresses to violet and whose extension is variable. It is generally associated with spontaneous pain and pain on palpation, as well as edema and possible temporary loss of muscle function.
- The clinical diagnosis of a deep hematoma may be more difficult to establish. If suspected, it may be necessary to resort to imaging support to define the diagnosis. Identification of deep hematoma may only be possible 12-72 hours after the traumatic event.
- Deep hematoma, especially if it is extensive, may have a worse prognosis/greater likelihood of complications such as myositis ossificans or fibrosis. Recovery should be longer.
- Signs of a worse prognosis include: increased pain and swelling/edema after 48-72 hours, decreased peripheral pulses, weakness or paresthesias at a level lower than the injury/trauma.
- Etiology:
- Traumatic
- direct trauma: consequence of an impact against an external blunt object or against a bone.
- indirect trauma: excessive or uncoordinated muscle contraction.
- Spontaneous
- extravasation of blood in a muscle group, without trauma, often associated with anticoagulant therapy in older patients.
- It occurs mainly at the level of the anterior/posterior abdominal muscles and buttock muscles.
- Depending on the extent of the hematoma and the patient’s comorbidities, it can be associated with potentially fatal conditions with mortality rates between 4 and 20%.
- Traumatic
Treatment
The approach to the hematoma must take into account its traumatic versus spontaneous etiology:
- Traumatic hematoma: conservative treatment (RICE) is recommended
- Rest: recommended during the first 24-72 hours after the traumatic event in order to avoid continued bleeding and exacerbation of fibrillar necrosis.
- Ice: applying cold compresses to the area in cycles of 12-15 minutes every 2-3 hours reduces edema and underlying inflammation.
- Compression: elastic compression for 2-7 days improves vascular drainage. The intensity of compression is not established, but in any case it should not induce pain or signs of poor perfusion.
- Elevation: elevation of the injured limb can contribute to the resolution of the hematoma by reducing blood pressure and increasing venous reflux.
- In the 2nd phase of conservative treatment, joint mobilization should be encouraged, both active and passive:
- The duration of immobilization should be limited to a short period, sufficient to produce a scar capable of withstanding the forces induced by remobilization.
- muscular activity (mobilization) must be started gradually and progression must be controlled individually through the pain threshold and function.
- Analgesia: some recommendations suggest using NSAIDs only after the first 48 hours, and never more than 7 days, so as not to interfere with the biochemical process of chemotaxis and satellite cell differentiation. Paracetamol is also effective as an analgesic.
- Spontaneous hematoma
- Depending on the size of the hematoma and the patient’s comorbidities, a spontaneous hematoma may have the potential to evolve and lead to hemodynamic instability/compartment syndrome. Hospital referral should be considered to identify the vascular structure that originates it (TAC or AngioTAC) and subsequent therapeutic guidance:
- initial conservative measures such as correction of altered coagulation parameters, fluid resuscitation and blood transfusion are generally sufficient in hemodynamically stable patients;
- Endovascular procedures are preferable in unstable patients, while a surgical approach may be indicated in the case of a compressive hematoma.
- Depending on the size of the hematoma and the patient’s comorbidities, a spontaneous hematoma may have the potential to evolve and lead to hemodynamic instability/compartment syndrome. Hospital referral should be considered to identify the vascular structure that originates it (TAC or AngioTAC) and subsequent therapeutic guidance: