Should You Close a Wound from a Hematoma?
Do not close a wound from a hematoma if the hematoma is compromising the vascular supply or causing significant tissue tension; instead, evacuate the hematoma surgically first, then reassess for delayed primary closure after ensuring adequate hemostasis and tissue viability. 1
Initial Assessment of the Hematoma
Determine if the hematoma requires surgical evacuation:
- Evacuate immediately if: The hematoma is causing luminal compromise of underlying vessels (detected by high-frequency bruit on auscultation or altered intravascular pressure on palpation), expanding with increasing skin tension, or causing overlying skin necrosis from tissue pressure 1, 2
- Conservative management if: The hematoma is small, stable, and not compromising tissue perfusion—in this case, rest the area until margins are well-demarcated before considering any closure 1
- Use duplex Doppler ultrasound (DDU) to confirm the extent of hematoma and assess for vascular compromise when physical examination is equivocal 1
Timing and Method of Wound Closure After Hematoma Management
If surgical evacuation was required:
- Do not close primarily if the wound is contaminated, contains purulent material, or shows devitalized tissue that cannot be adequately debrided 3
- Consider delayed primary closure 2–5 days after initial evacuation and debridement if the wound was contaminated or if tissue viability remains uncertain 3
- Primary closure is acceptable only after confirming: adequate hemostasis, complete removal of necrotic tissue, absence of infection, and sufficient tissue perfusion 4, 5
Closure technique when appropriate:
- Use absorbable sutures in a subcutaneous position to minimize scar thickness 1
- Support closure with externally applied sterile adhesive strips (Steri-Strips) 1
- Avoid closing under tension, as this compromises blood supply and increases dehiscence risk 6
Post-Evacuation Wound Management
Immediate post-procedure care:
- Apply a light pressure dressing for 12–24 hours to prevent re-accumulation of blood 7
- Elevate the affected extremity to reduce swelling and accelerate healing 1, 7
- Monitor for minimal serosanguineous drainage, which is normal in the first 24–48 hours 7
Red flags requiring urgent re-evaluation:
- Expanding erythema >5 cm around the wound 7
- Fever >38.5°C or heart rate >110 bpm 7
- Severe pain disproportionate to the injury 7
- Continuous bright red bleeding saturating dressings repeatedly 7
- Purulent discharge rather than serosanguineous drainage 7
Antibiotic and Prophylaxis Considerations
Antibiotic prophylaxis is indicated if:
- The wound is contaminated or dirty (soil exposure, devitalized tissue) 3
- The patient has risk factors such as diabetes, immunosuppression, or peripheral vascular disease 3
- The hematoma was associated with significant tissue trauma or open fracture 3
Antibiotic selection:
- First-line: Amoxicillin-clavulanate or first-generation cephalosporin for most traumatic wounds 3
- Add penicillin if severe soil contamination with extensive tissue damage (anaerobic coverage) 3
- Duration: 48–72 hours for prophylaxis; extend only if infection develops 3
Tetanus prophylaxis:
- Administer tetanus toxoid (Tdap preferred) if the patient has not received a booster within 10 years 3, 6
Critical Pitfalls to Avoid
- Never close a wound primarily if purulent material, significant contamination, or devitalized tissue is present—this guarantees infection and dehiscence 3
- Do not ignore expanding hematomas—tissue pressure can cause overlying skin necrosis even without infection 2
- Avoid inadequate irrigation—copious mechanical cleansing with sterile saline is as important as any other intervention in preventing infection 6, 5
- Do not assume early fever or drainage means infection—surgical site infections rarely occur within 48 hours; early symptoms are usually from normal inflammation or minor bleeding 7
- Recognize that hematomas can lead to access loss in vascular access sites—surgical treatment is mandatory if luminal compromise is present 1