Hematoma of the Lower Extremity: Operative Interventions in the Wound Clinic Setting

Terry Treadwell, MD, FACS, FAAWC

Disclosures

Wounds. 2022;34(3):90-93. 

In This Article

Abstract and Introduction

Abstract

Dear Readers: Hematoma in the soft tissue, a swelling in the tissue caused by bleeding, is not an uncommon occurrence following trauma or operative procedures. Hematomas of the extremities can be seen in as many as 33 per 10 000 individuals annually. Most hematomas are considered minor problems following the initial injury; however, accumulation of blood in the tissues can result in necrosis of the overlying skin due to increased tissue pressure. Even in the absence of increased tissue pressure, multiple cellular and biochemical changes that can result in tissue ischemia and necrosis have been identified. To avoid these significant complications, prompt recognition and operative evacuation of these hematomas should be performed. The author presents 2 cases of hematomas that were evacuated using local anesthesia in the wound clinic setting.

Introduction

Hematoma in the soft tissue, a swelling in the tissue caused by bleeding, is not an uncommon occurrence following trauma or operative procedures. Hematomas of the extremities can be seen in as many as 33 per 10 000 individuals annually.[1] Most hematomas are considered to be minor problems following the initial injury; however, accumulation of blood in the tissues can result in necrosis of the overlying skin due to increased tissue pressure which occludes the subdermal and dermal capillaries.[1,2] Even in the absence of increased tissue pressure, multiple cellular and biochemical changes that can result in tissue ischemia and necrosis have been identified.[2–4] Platelets and white blood cells in the wound can release inflammatory cytokines, proteolytic enzymes, and toxic reactive oxygen species causing significant tissue damage.[2] Iron ions present in the tissues from the lysis of the red blood cells and removal of hemoglobin molecules can cause a significant inflammatory reaction and thrombosis of the microvasculature.[3,4] Some of these untreated hematomas do not resolve and can result in painful, fibrotic masses at the site of the previous injury (Figure 1).

Figure 1.

Chronic, fibrosed, painful hematoma of the leg at the site of previous injury.

Interestingly, studies have shown that wounds with hematomas of the lower leg are associated with increased mortality within 2 years of the injury.[5,6] Prompt recognition and operative evacuation of these hematomas should be performed to avoid significant complications, and in the author's experience, most evacuations can be done in the clinic setting. To provide an alternative option to surgical procedures in the operating room, this report presents 2 cases and additional examples of hematomas that were evacuated using local anesthesia in the wound clinic setting.

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