What is the appropriate management for a patient with a delayed onset hematoma or possible worsening fracture after an injury?

Management of Delayed-Onset Hematoma After Injury

For a patient presenting with a bump that developed hours after injury, immediate clinical assessment is required to determine hemodynamic stability, rule out expanding hematoma with vascular injury, and evaluate for underlying fracture—with management prioritizing physiologic stability over immediate surgical intervention if the patient is unstable. 1, 2

Initial Assessment and Risk Stratification

The delayed appearance of swelling hours post-injury raises concern for evolving hematoma formation, which may indicate:

• Ongoing bleeding from vascular injury requiring urgent CT angiography if hard signs of vascular injury are present (expanding hematoma, pulsatile bleeding, absent distal pulses) 1
• Underlying fracture with delayed soft tissue swelling that requires radiographic evaluation 3
• Compartment syndrome risk if the hematoma is in a confined anatomic space, necessitating serial neurovascular examinations 1

Critical Physiologic Parameters to Assess

Determine the patient's stability status immediately, as this dictates the entire treatment pathway 1, 2:

• Hemodynamic status: Blood pressure, heart rate, signs of shock 1
• Respiratory function: Oxygen saturation, work of breathing 1
• Coagulation status: History of anticoagulation, bleeding disorders 1
• Associated injuries: Concurrent trauma to other body regions 1

Imaging Strategy

• Plain radiographs are the initial study for suspected fracture with focal tenderness and swelling 3
• CT angiography has 96.2% sensitivity and 99.2% specificity for detecting vascular injuries and should be obtained if vascular injury is suspected based on mechanism or clinical findings 1
• Ultrasound can be used at point-of-care to assess hematoma size and guide potential aspiration if indicated 4

Management Algorithm Based on Stability

For Hemodynamically Stable Patients

Early definitive treatment within 24 hours is recommended if an underlying fracture is identified and the patient has no severe associated injuries 1, 2:

• Proceed with definitive fracture fixation to reduce local and systemic complications 1
• This approach specifically reduces risk of fat embolism syndrome, respiratory complications, and multiple organ failure 2
• The hematoma itself should generally be preserved, as it contains essential inflammatory mediators and coagulation factors that promote fracture healing 5, 6

For Hemodynamically Unstable Patients

Delayed definitive treatment using damage control principles is recommended 1, 2:

• Implement aggressive resuscitation first, addressing the "lethal triad" of coagulopathy, acidosis, and hypothermia 1
• Use temporary stabilization with external fixation or skeletal traction if fracture is present 1
• Delay definitive osteosynthesis until after day 4 once physiologic parameters normalize 1
• The "PRompt Individualised Safe Management" (PRISM) approach prioritizes correction of hemodynamic, respiratory, and coagulation derangements before surgical intervention 1, 7

Specific Considerations for Hematoma Management

When to Preserve the Hematoma

The fracture hematoma contains critical healing factors and should be preserved in most cases 5, 6:

• Removal of hematoma, especially after 2-4 days, significantly impairs fracture healing by decreasing callus production, bending moment, and fracture energy 6
• The hematoma represents the initial phase of fracture healing with bidirectional interactions between inflammation and coagulation 5

When Intervention May Be Needed

• Expanding hematoma with vascular injury: Requires angiography with possible embolization or surgical exploration for hemorrhage control 1
• Compartment syndrome: Requires emergent fasciotomy regardless of hematoma presence 1
• Hematoma block for fracture reduction: Can be safely performed using ultrasound guidance without increasing infection risk if sterile technique is maintained 8, 4

Critical Pitfalls to Avoid

• Do not rush unstable patients to surgery: The surgical "second hit" from premature intervention triggers massive inflammatory mediator release, leading to multiple organ failure and increased mortality 1, 7
• Do not routinely evacuate fracture hematomas: This impairs healing, with worse outcomes when removed at 2-4 days compared to immediate removal 6
• Do not delay imaging in high-risk mechanisms: CT angiography should be obtained promptly when vascular injury is suspected to avoid missed injuries 1
• Do not assume stability based on initial presentation: Serial examinations are essential as delayed hematoma expansion may indicate ongoing bleeding requiring intervention 1

Timing of Definitive Treatment

The optimal window for definitive fracture fixation depends on stability 1:

• Stable/borderline patients: Within 24 hours reduces complications and improves outcomes 1, 2
• Unstable patients: Delay until after day 4, with complication rates significantly increased when surgery performed on days 2-4 1
• Safe definitive surgery: Should be performed as early as possible once hemodynamic, respiratory, and coagulation parameters normalize 1