What is the protocol for bone or bruise involvement?

Protocol for Bone Bruise or Bone Involvement Management

The management protocol for bone bruise or bone involvement depends on the specific location, patient age, and injury mechanism, with treatment approaches ranging from conservative management to surgical intervention based on associated injuries and patient characteristics. 1, 2

Bone Bruise Evaluation and Diagnosis

• Bone bruises are commonly identified on MRI as subchondral injuries that are not visible on plain radiographs, occurring in approximately 18.7% of patients with acute knee trauma 3
• MRI is the gold standard for diagnosing bone bruises, as these injuries show characteristic signal changes while appearing normal on standard radiographs 4
• Bone bruises are frequently associated with soft tissue injuries, with 94% of patients with bone bruises also having meniscal, ACL, or MCL injuries 2
• The natural history of bone bruises typically shows resolution within 4-12 months after injury, with 69% still present at 4 months and only 12% remaining at 12 months 2

Management Protocols by Location

Knee Bone Bruise Protocol

1. Initial Assessment

   • For ACL injuries with associated bone bruises, MRI evaluation should assess the distribution pattern and volume of bone bruises 5, 6
   • The lateral tibial plateau is the most common site for bone bruises (88.3%) in ACL injuries, followed by the lateral femoral condyle (76.7%) 5

2. Treatment Approach

   • For isolated bone bruises without significant ligamentous injury, activity modification is considered appropriate (rated 7/9 by AAOS) 1
   • For ACL tears with bone bruises, treatment options include:
     • ACL reconstruction with autograft (rated 8/9 by AAOS) 1
     • ACL reconstruction with allograft (rated 7/9 by AAOS) 1
     • Supervised rehabilitation program without reconstruction (rated 6/9 by AAOS) 1

3. Return to Activity

   • Bone bruise volume does not appear to significantly affect time to return to play or functional outcomes at 2 years post-ACL reconstruction 5
   • Patients with bone bruises initially show poorer function (Noyes score of 313.21 vs 344.81 in those without bone bruises) but demonstrate greater clinical improvement within 6 months 3

Calcaneal Bone Bruise Protocol

• Gradual weightbearing progression is essential to prevent complications such as chondrolysis and stress fractures 4
• Resolution of pain may take 2 weeks to 4 months depending on the extent of the injury 4
• Complete resolution of MRI signal changes typically occurs within 6 months 4

Special Considerations for Pediatric Patients

• In skeletally immature patients with open physes, bone bruise patterns differ significantly from those with closed physes 6
• Bone bruises in pediatric patients with open physes less frequently cross the physis and extend into the metaphysis (25% vs 85% for tibia; 4% vs 42% for femur) 6
• For children under 24 months with bruising, a skeletal survey (SS) is necessary in specific circumstances:
  • Any witnessed or confessed history of abuse causing bruise 1
  • History of domestic violence causing bruise 1
  • Additional injuries on examination (e.g., whip marks, burns) 1
  • Patterned bruises (showing imprint of an object) regardless of trauma history 1
  • All infants under 6 months with bruising, regardless of location or trauma history 1

Rehabilitation Protocol for Throwing Athletes with Shoulder Bone Involvement

The rehabilitation protocol for throwing athletes with shoulder bone or bruise involvement follows four phases 1:

1. Acute Phase

   • Modalities: cryotherapy, iontophoresis, ultrasound, electrical stimulation 1
   • Exercises: flexibility and stretching of posterior shoulder muscles, rotator cuff and scapular stabilization strengthening 1
   • No throwing permitted during this phase 1

2. Intermediate Phase

   • Focus on stretching internal rotation and horizontal adduction 1
   • Progressive isotonic strengthening 1
   • Initiation of core and lower extremity strengthening 1

3. Advanced Strengthening Phase

   • Plyometric program and endurance drills 1
   • Short-distance throwing program begins 1

4. Return-to-Activity Phase

   • Progressive interval throwing program following a data-based approach 1
   • For throwing arm with bruise or bone involvement: begin with step 1 and advance program as soreness rules allow, throwing no more than every other day 1

Common Pitfalls and Caveats

• Failure to obtain MRI when bone bruises are suspected can lead to missed diagnoses, as radiographs appear normal in these injuries 4
• Premature return to full weightbearing with calcaneal bone bruises may increase risk for chondrolysis and stress fractures 4
• In pediatric patients, failure to consider the unique bone bruise patterns related to open physes may lead to inappropriate management 6
• For suspected child abuse cases, not following appropriate skeletal survey guidelines may result in missed opportunities for intervention and prevention of further injury 1