What are the typical physical exam findings and management of a hematoma?

Physical Examination Findings and Management of Hematoma

The physical examination findings of a hematoma include swelling, discoloration, pain, and potential functional impairment, with management focused on identifying the underlying cause, preventing expansion, and addressing complications through a combination of observation, compression, elevation, and in some cases, surgical evacuation.

Physical Examination Findings

Visual Inspection

• Swelling: Localized enlargement at the site of injury 1
• Discoloration: Initially red or purple, evolving to blue, green, yellow, and brown as the hematoma ages
• Asymmetry: Comparison with the contralateral side reveals differences in size and contour 1
• Skin changes: Potential breakdown or necrosis in severe cases due to pressure from accumulated blood 2

Palpation

• Consistency: Fluctuant mass that may feel firm or soft depending on age of hematoma
• Temperature: Local warmth in acute hematomas due to inflammatory response
• Tenderness: Pain with direct pressure over the hematoma 1
• Intravascular pressure: Palpable difference in pressure along blood vessels in vascular-related hematomas 1

Functional Assessment

• Range of motion: Limited movement of affected area due to pain or mechanical obstruction
• Neurovascular status: Assessment of circulation, sensation, and mobility to identify potential complications 1
• Pain with movement: Indicates potential involvement of underlying structures

Diagnostic Evaluation

Imaging

• Ultrasound: First-line imaging modality for soft tissue hematomas, can identify fluid collections and assess vascular flow 1, 3
• CT scan: Preferred for suspected retroperitoneal or intracranial hematomas; can determine size, location, and potential active bleeding 3
  • Acute hematomas appear as high-attenuation areas
  • Subacute to chronic hematomas show mixed or low attenuation 3
• CT angiography (CTA): Indicated when active bleeding is suspected; can detect bleeding rates as low as 0.3 mL/min 3
• MRI: Superior for identifying chronic hematomas and associated conditions like vascular malformations 3

Management Approach

Initial Management

1. Rest and immobilization of the affected area to prevent further bleeding
2. Elevation of the affected limb above heart level to reduce swelling
3. Cold application in the first 24-48 hours to reduce bleeding and inflammation
4. Removal of constrictive items (rings, tight bandages) to prevent circulatory compromise 1

Medical Management

• Pain control: Analgesics as needed, avoiding NSAIDs in acute phase to prevent increased bleeding
• Correction of coagulopathy: For patients on anticoagulants with significant hematomas 3
  • Vitamin K, fresh frozen plasma, prothrombin complex concentrates, or recombinant factor VIIa may be indicated 3

Surgical Management

• Indications for surgical evacuation:

  • Expanding hematoma with neurovascular compromise
  • Compartment syndrome
  • Significant pain not responsive to conservative measures
  • Infection of the hematoma
  • Cosmetic concerns (in select cases) 2

• Surgical options:

  • Needle aspiration for accessible, liquefied hematomas
  • Incision and drainage for larger or organized hematomas
  • Formal surgical evacuation with potential vascular repair for complex cases 3

Special Considerations by Location

Subcutaneous/Soft Tissue Hematomas

• Usually self-limiting and resolve with conservative management
• Monitor for skin necrosis due to pressure effects 2

Retroperitoneal Hematomas

• May present with flank pain, hypotension, and decreasing hemoglobin
• CT is the diagnostic modality of choice 3
• Large or expanding hematomas may require angiographic embolization or surgical intervention 3

Intracranial Hematomas

• Present with headache, altered mental status, focal neurologic deficits
• Require urgent neuroimaging and neurosurgical consultation
• Management depends on size, location, and neurological status 3, 4

Rectus Sheath Hematomas

• May mimic acute abdomen
• Risk factors include anticoagulation therapy, trauma, and pregnancy
• Can lead to abdominal compartment syndrome requiring surgical decompression in severe cases 5

Monitoring and Follow-up

• Serial examinations: Monitor for expansion, increasing pain, or signs of infection
• Follow-up imaging: Consider for large or complex hematomas to ensure resolution
• Red flag symptoms requiring immediate attention:
  • Increasing pain
  • Spreading erythema
  • Development of systemic symptoms (fever, tachycardia)
  • Signs of compartment syndrome (pain out of proportion, paresthesias, pallor, pulselessness) 1

Prevention of Complications

• Early mobilization: Once acute phase has passed, to prevent joint stiffness
• Compression therapy: To prevent reaccumulation after drainage
• Anticoagulation management: Careful consideration of risks/benefits in patients requiring continued anticoagulation 3

Remember that prompt recognition and appropriate management of hematomas can prevent serious complications such as compartment syndrome, infection, and tissue necrosis.