Treatment of Lower Extremity Hematoma
For closed lower extremity hematomas, apply localized cold therapy (ice pack or instant cold pack) with or without compression for a minimum of 10 minutes, as this reduces hematoma size and blood loss more effectively than compression alone. 1
Initial Assessment and Management
When a lower extremity hematoma develops, immediately assess:
- Size and expansion: Measure the hematoma surface area and monitor for growth 1
- Vascular status: Check for presence of pulses both proximal and distal to the hematoma 1
- Extremity circulation: Evaluate perfusion to the entire affected limb 1
- Overlying skin integrity: Look for signs of tissue necrosis from increased pressure 2
Primary Treatment Protocol
Apply cold therapy immediately using an ice pack or instant cold pack directly to the hematoma site for at least 10 minutes, continuing up to 180 minutes with intermittent applications. 1 Evidence from post-cardiac catheterization patients demonstrates that cold compression reduces hematoma size by approximately 20 cm² over 3 hours compared to only 10 cm² with compression alone. 1, 3
Add compression after or during cold application by applying direct pressure or a compression dressing. 1 In post-surgical patients (such as total knee arthroplasty), cold compression reduces total blood loss by 610 mL and extravasation by 357 mL compared to no cold therapy. 1
Elevate the extremity if feasible, though evidence for this intervention is limited. 1
When to Escalate to Surgical Evacuation
Operative evacuation under local anesthesia is indicated when:
- The hematoma causes overlying skin necrosis due to increased tissue pressure 2
- Progressive expansion occurs despite conservative measures 2
- Tissue ischemia develops from cellular and biochemical changes 2
Prompt recognition and evacuation prevents significant complications including tissue necrosis. 2 This can be performed in an outpatient wound clinic setting using local anesthesia. 2
Critical Pitfalls to Avoid
Do not remove initial dressings prematurely to check if bleeding has stopped, as this disrupts clot formation. 4
Monitor for compartment syndrome by assessing for pain out of proportion to examination, paresthesias, and diminished pulses—these require emergent fasciotomy, not just hematoma management. 5
In pediatric patients, use caution with prolonged cold therapy application to avoid hypothermia risk, though localized application to a limited area (such as with an instant cold pack to a bruise) should not cause systemic hypothermia. 1
Avoid aggressive manipulation of expanding hematomas near major vessels, as these may indicate arterial injury requiring vascular surgery consultation. 1, 5
Special Considerations for Post-Procedural Hematomas
For femoral hematomas after cardiac catheterization, cold pack therapy is superior to sandbag compression, showing statistically significant reduction in hematoma size (95% CI, P < 0.05) and better patient satisfaction. 3 Apply the cold pack directly to the groin site for 30-minute intervals over 3 hours. 3
For post-operative orthopedic patients, initiate cold compression therapy immediately postoperatively to minimize blood loss and hematoma formation. 1
Duration and Follow-up
Continue cold therapy applications intermittently for up to 3 hours or until hematoma stabilization is confirmed. 1, 3 Reassess hematoma size at 30-minute intervals during the initial treatment period. 3 If the hematoma continues to expand despite appropriate conservative management, proceed to surgical evaluation for possible evacuation. 2