What treatment is recommended for an elderly female with a large hematoma and swelling on the medial leg below the knee, 8 days after a traumatic injury?

Management of Large Leg Hematoma in an Elderly Female

For this elderly patient with a baseball-sized hematoma 8 days post-injury, immediate medical evaluation is essential to rule out compartment syndrome, assess for underlying fracture, and determine if surgical evacuation is needed—conservative management with elevation, ice, and monitoring is appropriate only if there are no signs of neurovascular compromise, expanding hematoma, or infection. 1

Immediate Assessment Required

This patient needs urgent clinical evaluation because:

• Time-sensitive complications: While the initial "golden period" for preventing major complications is within 6 hours of injury 2, at 8 days post-injury you must now assess for delayed complications including infection, compartment syndrome, and tissue necrosis 3

• High-risk population: Elderly patients have increased vulnerability to complications from soft tissue injuries, including impaired healing, higher infection rates, and potential for skin breakdown 1

• Size and location matter: A baseball-sized hematoma on the medial leg below the knee suggests significant soft tissue injury that could involve neurovascular structures or indicate underlying fracture 1

Critical Evaluation Steps

Assess for Compartment Syndrome

• Check for the "5 P's": Pain (especially with passive stretch), Pressure, Paresthesias, Pallor, and Pulselessness 1
• Compartment syndrome can develop late, even days after initial injury 3
• If any signs present: This is a surgical emergency requiring immediate fasciotomy 1

Evaluate Neurovascular Status

• Palpate distal pulses (dorsalis pedis and posterior tibial) 1
• Test sensation in all nerve distributions of the lower leg 1
• Assess motor function of ankle and toe movements 1

Look for Signs of Infection

• Wound infections are the most common complication in lower extremity trauma, occurring in 23-34% of cases 3
• Check for: increasing warmth, erythema spreading beyond the hematoma, purulent drainage, fever, or systemic signs 3
• If infection suspected: Requires urgent surgical drainage and antibiotics 3

Determine if Hematoma is Expanding

• Measure and document the size precisely 1
• Ask about progressive swelling over the past 8 days 1
• Expanding hematoma: May indicate ongoing bleeding requiring surgical intervention 1

Imaging Required

Obtain plain radiographs immediately to rule out underlying fracture, which occurs commonly with high-energy blunt trauma and changes management significantly 4, 2

Consider ultrasound or CT if:

• Clinical examination suggests deep hematoma involving muscle compartments 1
• Concern for vascular injury exists 1
• Planning surgical evacuation to define extent 1

Treatment Algorithm

If NO Red Flags (no compartment syndrome, stable neurovascular exam, no infection, not expanding):

Conservative management is appropriate 5:

• Elevation: Keep leg elevated above heart level as much as possible to reduce swelling 5
• Ice application: 20 minutes on, 20 minutes off for first 48-72 hours (though at 8 days, benefit is limited) 5
• Compression: Gentle compression bandaging if tolerated, avoiding excessive pressure 5
• Pain management: Multimodal analgesia using acetaminophen and NSAIDs (if not contraindicated in elderly patient); avoid opioids if possible 5
• Monitor closely: Daily assessment for expansion, infection, or neurovascular changes 1
• Mobilization: Gentle range of motion exercises once acute pain subsides to prevent stiffness 4

If ANY Red Flags Present:

Immediate surgical consultation required 1:

• Compartment syndrome → Emergency fasciotomy 1
• Expanding hematoma → Surgical exploration and hemostasis 1
• Infected hematoma → Incision, drainage, debridement, and antibiotics 3
• Underlying fracture → Orthopedic management per fracture type 4

Critical Pitfalls to Avoid

• Don't dismiss based on time elapsed: Complications including infection and late compartment syndrome can develop days after injury 3
• Don't assume "just a bruise": The mechanism (struck with stool) and size suggest significant force that could cause deeper injury 2
• Don't overlook anticoagulation: If patient is on antiplatelet agents or anticoagulants, hematoma expansion risk is higher and may require reversal 1
• Don't delay if expanding: Progressive swelling indicates active bleeding requiring intervention 1

Expected Complications

Even with appropriate management, be aware that:

• Wound complications including dehiscence occur in 13.4% of lower extremity injuries 3
• Rehospitalization for complications occurs in approximately one-third of patients with severe lower extremity injuries 3
• Complete resolution may take weeks to months depending on hematoma size 6

Follow-up Requirements

• Recheck within 24-48 hours if managed conservatively 1
• Return immediately if: increasing pain, numbness, weakness, fever, or expanding swelling 3
• Physical therapy referral once acute phase resolves to restore full function and prevent long-term disability 4, 6