Hematoma

There are several types of hematomas and they are often described based on their location.

A hematoma is an abnormal collection of blood outside of a blood vessel. It occurs when the wall of a blood vessel, artery, vein or capillary gets damaged and blood leaks into tissues where it does not belong. The hematoma may be tiny, with just a dot of blood, or it can be large and cause significant swelling.

The blood vessels in the body are under constant repair. Minor injuries occur routinely, and the body is usually able to repair the damaged vessel wall by activating the blood clotting cascade and forming fibrin patches. However, the repair may fail if the damage is extensive, leading to continued bleeding. If there is tremendous pressure within the blood vessel, such as in a major artery, the blood will continue to leak through the damaged wall, and the hematoma will expand.

Blood that escapes from within a blood vessel irritates the surrounding tissue and may cause symptoms of inflammation including pain, swelling and redness. Symptoms of a hematoma depend upon their location, size and whether they cause associated swelling or edema.

Hematomas may occur anywhere in the body. Regardless of how the condition is described or where it is located, it remains a collection of clotted blood outside a blood vessel.

Hematomas are often described based on their location. The most dangerous kinds are those that occur inside the skull. Because the skull is an enclosed container, anything that takes up space increases pressure within and potentially impairs the ability of the brain to function.

The different types of hematomas include the following:

• Epidural hematomas occur because of trauma, often to the temple, where the middle meningeal artery is located. Bleeding accumulates in the epidural space, outside the "dura" which is the lining of the brain. Because of the way the dura is attached to the skull, small hematomas can cause significant pressure and brain injury.
• Subdural hematomas also occur because of trauma, but the injury is usually to the veins in the brain. This causes a slower leak of blood, which enters the "subdural" space below the dura. The space below the dura has much more room for blood to accumulate before brain function suffers. As people age, they lose some brain tissue and the subdural space is relatively larger. Bleeding into the subdural space may be very slow, gradually stop and not cause acute symptoms. These "chronic" subdural hematomas are often found incidentally on CT scans as part of patient evaluations for confusion or after another traumatic incident. However, subdural hematomas may be large, cause associated brain swelling, and may be lethal.
• Intracerebral hematomas occur within the brain tissue itself. Intracerebral hematomas may be due to bleeding from uncontrolled high blood pressure, an aneurysm leak or rupture, trauma, tumor or stroke.
• Scalp hematomas occur on the outside of the skull and often can be felt as a bump on the head. Because the injury is to the skin and muscle layers outside of the skull, the scalp hematoma itself cannot press on the brain. Because these hematomas are often easily visible and can be relatively large they often cause significant concern for the patient.
• Ear hematomas may occur if an injury causes bleeding to the outside helix or cartilage structure of the ear. Often called boxer's ear, wrestler's ear or cauliflower ear, the blood becomes trapped between the thin layer of skin and the cartilage itself. Since the ear cartilage gets its blood supply directly from the overlying skin, a hematoma can decrease blood flow, causing parts of the cartilage to shrivel and die. This results in a bumpy, deformed outer ear called a "cauliflower ear."
• Septal hematomas occur with nasal trauma, such as a broken nose. If not recognized and treated, the cartilage can break down and cause a perforation of the septum.
• Intramuscular hematomas can be very painful due to the amount of swelling and inflammation. Some muscles are surrounded by tough bands of tissue. If excessive bleeding occurs, the pressure within these compartments can increase to the point that "compartment syndrome" can occur. In this situation, the blood supply of the muscle is compromised, and the muscle and other structures such as nerves can be permanently damaged. This is most commonly seen in the lower leg and forearm. Compartment syndrome may also be seen as a complication of fractures. This is a true surgical emergency. Medical care should be accessed immediately if compartment syndrome is suspected. For health care professionals, one clue to consider this diagnosis is finding a patient whose pain is out of proportion to the physical findings.
• Subungual hematomas are the result of crush injuries to the fingers or toes. Bleeding from this type of injury occurs under the fingernail or toenail, and because it is trapped, pressure builds up, causing pain. Trephination, or drilling a hole through the nail to remove the blood clot, relieves the pressure and resolves the injury. Over time, the nail repairs itself.
• Subcutaneous hematomas are bruises and contusions of the skin (ecchymosis). These occur due to trauma or injuries to the superficial blood vessels under the skin. Individuals who take anticoagulant medication are more prone to subcutaneous hematomas.
• Intra-abdominal hematomas and hemorrhage may be due to a variety of injuries or illnesses. Regardless of how the blood gets into the abdomen, the clinical finding is peritonitis (irritation of the lining of the abdomen). Hematomas may occur in solid organs such as the liver, spleen or kidney. They may occur within the walls of the bowel, including the small intestine (duodenum, jejunum and ileum) or the large intestine (colon). They may also form within the lining of the abdomen called the peritoneum or behind the peritoneum in the retroperitoneal space ("retro" means behind).
• Subchorionic hematoma: A subchorionic hematoma is a collection of blood that forms during pregnancy beneath the chorionic membrane, specifically between the placenta and uterus. This is one of the most typical ultrasound findings in the early stages of pregnancy.

How common is subchorionic hematoma in pregnancy?

Subchorionic hematomas occur in about 18 to 22 percent of intrauterine pregnancies with vaginal bleeding. It is the most common cause of vaginal bleeding in people who are 10 to 20 weeks pregnant. A subchorionic hematoma does not necessarily imply a high risk of miscarriage. Close monitoring and taking appropriate measures may aid in delivering a healthy baby.

What irritates a subchorionic hematoma?

Several factors may irritate or contribute to the development of a subchorionic hematoma. These include:

• Placental or vascular abnormalities: These include conditions such as placenta previa (where the placenta covers part or all of the cervix), placental abruption (where the placenta detaches from the uterine wall) and uterine fibroids.
• Trauma: Trauma to the abdomen, such as from an impact or a fall, can lead to bleeding around the gestational sac.
• Sexual intercourse: While relatively rare, vigorous sexual activities during pregnancy can cause bleeding and may irritate or contribute to the formation of a subchorionic hematoma.

Trauma is the most common cause of a hematoma. When people think of trauma, they generally think of car accidents, falls, head injuries, broken bones and gunshot wounds. Trauma to tissue also may be caused by an aggressive sneeze or an unexpected twist of an arm or leg. When a blood vessel is damaged, blood leaks into the surrounding tissue; this blood tends to coagulate or clot. The greater the amount of bleeding, the larger the amount of clot (hematoma) formation.

Can you get a hematoma on your hip from a fall?

Although rare, you can get a hematoma on your hip from a fall. A very rare clinical condition, known as subperiosteal hematoma (SPH) of the iliac bone, primarily affects young people who have recently had a fall or sports-related injury. After a fall, you may typically have extreme hip pain that mimics a femoral neck fracture. The hematoma site appears bruised, with its color changing from red and purple to yellow and green as it heals. This is because a break in the wall of a blood vessel causes blood to collect outside the vessel. The area can be painful and may swell due to the accumulation of blood and become tender to touch.

Conditions that cause hematomas include:

• Aneurysm: An aneurysm is a weakening and bulging of a blood vessel wall. Hematoma can occur when an aneurysm bursts, causing bleeding into the surrounding tissues. Traumatic brain injury is the most common cause of acute subdural hematoma (ASH). Subarachnoid hemorrhage is the most typical presentation of a ruptured aneurysm. However, in rare cases, the aneurysm may cause atraumatic ASH.
• Medications: Some blood thinners or anticoagulation medications may increase the risk for spontaneous bleeding and expansion of hematomas because the body cannot efficiently repair blood vessels. This allows blood to leak excessively through the damaged areas. These medications include
  • Coumadin (warfarin)
  • Aspirin
  • Plavix (clopidogrel)
  • Effient (prasugrel)
  • Xarelto (rivaroxaban)
  • Eliquis (apixaban)
• Diseases or conditions that may decrease the number of platelets in the bloodstream (thrombocytopenia) or diminish their function: Viral infections (rubella, parvovirus, mumps, chickenpox, HIV and hepatitis C), aplastic anemia, cancers from other organs, long-term alcohol abuse and vitamin D deficiency may be associated with hematomas.
• Orthopedic injuries: Fractures are always associated with hematomas at the fracture site. Fractures of long bones such as the thigh (femur) and upper arm (humerus) can be associated with a significant amount of bleeding.

Other conditions that cause hematomas include:

• Pelvic bone fractures: These breaks can also bleed significantly, as it takes a large amount of force to break these bones, which often damages nearby veins and arteries as well.
• Menstruation: During menstruation, blood can accumulate in the vagina as part of the normal menses, and instead of flowing out immediately, it may form small blood clots.
• Pregnancy: Vaginal bleeding and passing blood clots or hematomas while pregnant are not normal and are reasons to seek immediate medical attention.
• Labor and delivery: Passing clots after delivering a baby is relatively common.

Hematomas can affect anyone who gets injured. Athletes can sustain muscle trauma. People over the age of 60 are more prone to muscle injuries, but anyone can receive an injury, resulting in a hematoma on their head or body.

Hematomas cause irritation and inflammation of the surrounding tissues. Symptoms of a hematoma depend upon their cause (traumatic or other) , location and whether the size of the hematoma or the associated swelling and inflammation cause nearby structures to be affected.

Symptoms of hematomas may include:

• Headache
• Confusion
• Seizures (subdural hematoma symptom)
• Back pain
• Loss of bladder or bowel control (epidural hematoma)
• Discoloration
• Nail loss
• Pain in the nail bed
• Abdominal or flank pain (spleen, liver, or peritoneal hematoma)

The common symptoms of inflammation from hematoma include:

• Redness
• Tenderness
• Warmth
• Pain
• Swelling

Can a hematoma form scar tissue?

A hematoma can lead to the formation of scar tissue, especially if it is large or not properly resolved. In the event of a blood vessel rupture, platelets and other blood cells aggregate at the bleeding site to form blood clots. Usually, the body reabsorbs the collected blood over time; however, occasionally this process may not be successful, causing inflammation. Prolonged inflammation can stimulate the deposition of fibrous or scar tissue as part of the healing process.

Most hematomas are due to minor trauma. Usually, a person with a hematoma is aware of the injury, knows what part of the body was injured, and can expect to recover with few problems.

How serious is a hematoma?

Some hematomas may be more serious because of their location. Usually, symptoms are caused by the nearby affected areas.

Seek medical care in the following situations (this list is not exhaustive):

• A person with a head injury with accompanying headache, confusion, vomiting, slurred speech, muscle weakness, vision changes or difficulty being aroused should seek immediate medical attention.
• People taking blood thinners are at increased risk for significant bleeding from even minor injuries. It is often wise for these people to seek medical attention if they are involved in even minor accidents or sustain minor injuries.
• Blood clots in the urine require prompt evaluation. Hematomas that are large and within certain areas of the muscle of the arms and legs should be evaluated as space-occupying lesions and possible causes of compartment syndrome. Pain that’s out of proportion to the extent of the injury is a clue to this serious complication.
• Hematomas overlying large, smooth areas of bone or cartilage should be evaluated and possibly treated to avoid cosmetic disfigurement.

Hematomas of the skin and soft tissues, such as muscles and joints, are often diagnosed by physical examination alone.

For patients exhibiting signs of internal bleeding, the healthcare professional will decide the best imaging modality to evaluate the situation. Plain X-rays may be needed to assess for bone fracture. Patients with significant head injuries often require CT scans or MRI studies. Ultrasound is the testing modality of choice for those who are pregnant and often for suspected intraabdominal hematomas

Hematomas of the skin and soft tissues are often treated with rest, ice, compression, and elevation (RICE). Some health care professionals may advocate heat as another hematoma treatment alternative. The pain of a hematoma is usually due to the inflammation surrounding the blood and may be treated with over-the-counter pain medications. The choice of drugs depends upon the underlying health of the patient. For patients taking anticoagulation medications, ibuprofen is relatively contraindicated (not recommended) because of the risk of gastrointestinal bleeding. Patients with liver disease should not take over-the-counter acetaminophen. When in doubt, it is wise to ask the health care professional or pharmacist for a recommendation.

Treatment for hematomas involving other organs in the body depends upon what organ system is involved. In these cases, treatment will be tailored to the specific situation. The treatment of a hematoma or its removal must always take into consideration the initial cause and possibility or likelihood of recurrence if the initial, instigating factor has not been controlled or removed.

Should you use heat or ice for a hematoma?

The application of heat or ice to treat a hematoma depends on the timing of the injury. Here's how to use ice and heat effectively:

• Ice: You should use ice for the first 24 to 48 hours following the accident. Ice helps stop bleeding by narrowing blood vessels and reducing swelling and pain. Ice packs should be placed on the injury site for roughly 10 to 20 minutes at a stretch every few hours. It is important to remember not to apply ice directly on the skin, as it may cause frostbite. The initial application of ice reduces the hematoma's size.
• Heat: After the first 48 hours, when the bleeding has stopped, you can start using heat. Heat encourages blood flow, which can help remove blood clots and reduce any residual edema. If the hematoma is close to a muscle area, it also helps calm and relax the affected area. Heat can be applied several times a day for 15 to 20 minutes at a time using a heating pad or warm compress.

Should a hematoma be hard or soft?

The consistency of a hematoma varies depending on its healing stage. A hematoma usually progresses through various stages.

• Soft: Following an injury, the hematoma feels soft initially because there is a buildup of new blood beneath the skin or in the muscular tissue. The hematoma may get firmer as the blood starts to clot, which is a normal stage of the healing process.
• Firm: The clot may become hard or lumpy over time. As the body attempts to heal the wounded area, the blood clot starts drying up and there’s continuous production of fibrous tissue, causing hardness.
• Soft: The area may eventually soften once more as the hematoma heals and the body absorbs the blood. Depending on the extent of the hematoma, the patient's condition and how they react to the injury, the resolution process may take a few days to several weeks.

Seeking medical attention is advised if a hematoma does not seem to be improving with time or if it’s still hard, particularly if it’s causing pain or discomfort. A persistent, hard hematoma may occasionally be a sign of complications such as calcification or the development of a chronic encapsulated hematoma, both of which indicate prompt medical attention.

In general, superficial hematomas of the skin, soft tissue and muscle tend to resolve over time.

• The initial firm texture of the blood clot gradually becomes spongier and softer as the body breaks down the blood clot, and the shape changes as the fluid drains away and the hematoma flattens.
• The color changes from that of a purplish-blue bruise to yellow and brown as the blood components are gradually metabolized and the hematoma resolves.
• Depending upon its location, the discolorations may travel through different tissue planes by gravity. For example, a forehead hematoma may cause bruising beneath the eyes and seems to travel to the neck as it resolves over time.
• Intracranial, epidural, subdural, and intracerebral hematomas often need neurosurgical intervention to stabilize the injury.
• Some hematomas become calcified with time and cause a permanent lump. This heterotopic calcification can cause the hematoma to become integrated with underlying bone or cartilage making surgical removal difficult. There has been some success with the injection of long-acting steroids into hematomas that are in cosmetically important areas or areas prone to this complication to avoid permanent hard lesions.

Hematomas cause swelling and inflammation, which often result in irritation of adjacent organs and tissues. This causes the symptoms and complications of a hematoma. One common complication of all hematomas is the risk of infection. While the hematoma is made of old blood, it has no blood supply itself and therefore is at risk for colonization and the growth of bacteria to the point of possible true infection or sepsis.

Accidents happen and most hematomas are inevitable once the trauma has occurred.

For patients taking anticoagulation medications, it is wise to avoid participating in events with a high risk of injury. For patients taking Coumadin (warfarin), it is important to make certain that the dosing is appropriate and the blood is not thinned excessively.