Mechanism of injury and classification
All mechanical injuries are fundamentally divided into open and closed. Closed soft tissue injuries include conditions where the skin remains intact (crushes, strains, tears, and contusions). A contusion occurs as a result of impact from a blunt object with low kinetic energy or from a fall.
In clinical practice, contusions are classified by association and localization:
- By association: the injury may be isolated or associated (accompanied by bone fractures or contused wounds).
- By localization: external (superficial) contusions are distinguished, which include head and limb injuries, as well as contusions of internal organs. Injuries to internal organs (chest, abdomen, brain) are more serious prognostically, as they can be complicated by concussion or rupture.
Clinical presentation and "blooming" of the hematoma
The classic symptoms of a contusion consist of four main signs: the patient experiences localized pain, tissue swelling is determined visually and by palpation, a hemorrhage (hematoma) forms, and impairment of function of the damaged segment occurs.
An important diagnostic criterion is the assessment of the color of the bruise. The dynamics of the color change of the hematoma directly depend on the biochemical breakdown of hemoglobin from the extravasated blood. Assessing this sign allows the doctor to judge the time elapsed since the injury quite accurately:
- Fresh contusion (immediately after trauma and the first days): the hemorrhage has a pronounced red-purple color.
- 5–6 days later: due to the breakdown of hemoglobin, the color of the hematoma changes to green.
- Late stages: the bruise eventually acquires a yellow hue.
Diagnostic algorithm for limb contusions
During the physical examination of the injured limb, the surgeon must first rule out a more severe pathology—hidden bone damage, as well as compression of the neurovascular bundle due to pressure from a large hematoma. A strict diagnostic algorithm is used for this:
- Circulation assessment: mandatory determination and symmetrical comparison of pulsation in peripheral arteries to rule out ischemia.
- Thermometry: measurement and comparative analysis of skin temperature on both limbs (healthy and affected).
- Neurological status: thorough examination of sensation in peripheral areas to promptly detect compression of nerve trunks.
- Radiography: prescribed without fail at the slightest suspicion of a bone fracture or fissure.
Principles of treatment for contusions and hematomas
Therapeutic tactics for contusions change drastically depending on the time elapsed since the moment of injury.
First aid and first 24 hours: The main task is to stop the ongoing hemorrhage into the tissues. A pressure bandage is applied to the injury site and local cold (ice pack) is used. The cooling regimen must be strict: ice is applied for 2 hours, followed by a mandatory 30–40 minute break. When hemarthrosis (accumulation of blood in the joint) develops, complete rest must be ensured, the limb elevated, and a pressure bandage applied to the joint area.
Days 2–3: The tactics change to the opposite. To accelerate the resorption of the already formed hemorrhage, thermal procedures (heating pads, Sollux lamp) are prescribed.
Treatment of large hematomas: If the hematoma has a significant volume and does not resolve spontaneously, conservative tactics are supplemented by an invasive intervention. 5–7 days after the injury, a hematoma puncture is indicated. The doctor removes the accumulated blood, after which a pressure bandage is reapplied to the damaged area to prevent recurrent hemorrhage.
The "CTP" rule: Cold (day 1) — Thermal therapy (days 2–3) — Puncture (days 5–7 for large hematomas).
Class and exam questions
What is the fundamental difference between a contusion and a soft tissue tear?
In a contusion, the visible anatomical integrity of soft tissues and organs is preserved, whereas in tears, this basic structure is disrupted.
Why does a hematoma change its color over time?
The color change of the bruise from red-purple to green (by days 5–6) and yellow is associated with the sequential biochemical breakdown of hemoglobin.
Can warming compresses be applied immediately after a contusion?
Categorically no. In the first 24 hours, exclusively cold (ice pack) is used to reduce hemorrhage. Thermal procedures are indicated only from days 2–3.
How to treat extensive, non-resolving hematomas?
For large hematomas on days 5–7, a diagnostic and therapeutic puncture is performed: the accumulated blood is removed, after which a pressure bandage must be applied.
What else to study on this topic
- Biochemical mechanism of hemoglobin breakdown in tissues
- Features of the clinical presentation and diagnosis of internal organ contusions
- Diagnostic algorithm and puncture technique for hemarthrosis
- Differential diagnosis of a contusion and a closed bone fracture
- Technique of applying various types of pressure bandages
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