A Proposed Algorithm to Diagnose and Treat Lower Extremity Hematomas

In elderly patients, injury to the lower extremity, specifically the pretibial area, accounts for 5.2 of every 1000 emergency department visits per year.^1-7 While many of these injuries may seem minor, in a specific patient population, injuries to the leg have the potential to lead to significant soft tissue loss, the need for advanced medical and surgical management, a rapid decline in patient mobility and independence, and increased mortality potential.^1,2,8-11

Misdiagnosis and delayed referral for treatment often result in these complications and challenges in management.^8-11 Consensus or an evidence-based diagnostic and treatment protocol has the potential to improve clinical outcomes and reduce complications and extended hospitalization. The main objective of this guidance would be avoidance of the need for complex surgical intervention and hospitalization.⁷ Yet, neither exists.¹ The aim of this study was to develop an easy-to-follow algorithm to aid in the identification and treatment of these injuries in the patient population at greatest risk.

The authors performed a search of PubMed and the Google Scholar database for literature published from 2000 through 2020. Search terms were pretibial, soft-tissue injury, lower extremity, lower extremities, leg injury, lower leg injuries, hematoma, degloving, dermatoporosis, deep dissecting hematoma, anticoagulant, anticoagulation, flowchart, and algorithm. Articles reviewed were restricted to the English language and those that discussed identification and treatment of hematoma on the leg. Articles that mentioned hematoma as an adverse event related to a separate condition or treatment were excluded. Commonalities in the reported literature were identified to create a simple algorithm for the early identification and treatment of lower extremity hematomas with the intent of improving outcomes of future patients. A recent case of deep dissecting hematoma treated by one of the authors (WC) was also reviewed to provide an example of how this algorithm could be implemented to yield an accurate diagnosis and initiate treatment more promptly, potentially avoiding development of a deep dissecting hematoma and subsequent advanced and prolonged care.

Literature review. Review of the literature identified 30 articles, all of which were screened for inclusion (Figure 1). Two articles were eliminated as they discussed only prevention or postoperative hematoma as a cause for failure in flap surgery. The remaining 28 articles were retrieved and reviewed. Five articles were eliminated as they did not mention hematoma, or hematoma was mentioned only as an adverse event of treatment. This left 23 articles for use in the development of the Lower Extremity Hematoma Algorithm (LEHA) algorithm. These articles identified risk factors and mechanisms of injury that should increase the provider’s index of suspicion for the development of a deep dissecting hematoma of the lower extremity. Common early and late presentation findings and recommended treatments were also identified.

Patients primarily at risk for complicated, deep dissecting hematomas of the lower extremity requiring advanced intervention were female and had multiple comorbidities; many were taking corticosteroids and/or anticoagulant therapy, had impaired vision, were malnourished, and had reduced independence or mobility (Table 1).^1-19 Overall, most patients who developed a deep dissecting hematoma were elderly, most often ≥80 years of age.^{1,2,6-7,10,16}

The predominance of deep dissecting hematomas in the elderly has been attributed to the presence of dermatoporosis, a condition characterized by atrophy of the epidermis and dermal collagen and loss of cutaneous vasculature that results in mechanical fragility of the skin, making it vulnerable to shear and friction.^2,3,5,6 Subcutaneous vessels are also closer to the surface, making them more prone to injury that results in bleeding.^2,3,10 Dermatoporosis first manifests around 60 years of age. Prevalence of dermatoporosis in patients ≥65 years is 37.5%; by age 70 years, the condition is typically fully developed.^2,18

Deep dissecting hematomas are reported to affect more women than men, with the reported female-to-male ratio ranging from 3:2 to 6:1.^3-5,7,10,18 Patients often have multiple comorbidities, most notably peripheral vascular disease, edema, diabetes, chronic renal failure, and conditions necessitating the use of anticoagulant therapy, such as chronic atrial fibrillation, venous thromboembolism, recurrent transient ischemic attacks, and ischemic cerebrovascular accidents.^3-9,13,16,18 Anticoagulant therapy use is especially prevalent; over 20% of patients who develop deep dissecting hematomas are on warfarin.^{3-7,9,11,12,15,17,18} Systemic or inhaled corticosteroid use is also common.^{2,3,5,6,15,17-19} Patients may also be malnourished and have impaired vision, independence, and mobility status, all of which put them at risk for falls and leg injuries.^2,3,5,6,15

The mechanism of injury preceding deep dissecting hematoma of the leg is often minor, being a ground level fall or trip or low impact, blunt trauma sustained in the home.^3-6,8-11 Even in the absence of patient-reported significant injury, this mild trauma can be enough for hematoma formation and tissue injury to occur. The development of deep dissecting hematomas greater than 10.0 cm in diameter has been reported to occur in patients with severe comorbidities even if no open wound or laceration was present.²⁰

Early presentation of these hematomas are characterized by pain, tenderness, edema, ecchymosis, erythema that resolves with elevation, and no local or systemic signs of infection.^2,11,18 If misdiagnosed or inappropriately treated, deep dissecting hematoma can develop due to the shearing of the soft tissue from the underlying deeper fascial layers and subsequent vascular damage sustained, resulting in hematoma development between the subcutaneous tissue and deep fascial layers. Expansion of this hematoma can result in pressure levels that exceed capillary perfusion pressures, resulting in the late presentation of skin and soft tissue necrosis.^8,13,15

Preclinical studies on the effect of hematoma formation on flap failure have speculated that biochemical and cellular effects of the hematoma on the surrounding tissue play a large role in subsequent tissue damage and necrosis.²¹ These studies have demonstrated that the presence of a hematoma causes neutrophil activation, cytokine-mediated inflammation, release of reactive oxygen species, and activation of the complement cascade. This sequence of events leads to the physical destruction of capillary beds, resulting in thrombosis and tissue necrosis independent of the extrinsic pressure the hematoma placed on the local circulation. This may explain why tissue damage can occur with as little as 4 hours of contact with a hematoma. Thus, immediate hematoma evacuation is recommended because signs of tissue compromise are typically clinically evident.²¹

Treatment methods employed have been noninvasive or percutaneous evacuation or liposuction for removal of the hematoma, followed by application of a compressive dressing.^12-14 However, these methods have the potential to fail as a result of incomplete evacuation due to insufficient penetration and the potential for hematoma reaccumulation.^2,6,9 Evacuation in the outpatient setting should only be performed if the patient is hemodynamically stable, the facility has the means for stabilizing a bleeding patient, and access to the level between the subcutaneous tissue and deep fascial layer can be obtained.⁷ Evacuation should be followed by the application of a compression dressing to help prevent hematoma reaccumulation. It is also recommended that any incision be made at the periphery of the nonviable tissue to avoid the area where the cutaneous vascular supply has been compromised.²

Clinical outcomes for these patients are improved when these procedures are performed closer to the date of the initial injury and surgical management is employed.^1,5,6 Early surgical intervention has been demonstrated to reduce time to healing by 68% (13 days vs 41 days) compared with conservative management.¹ Average time to healing was 55 days when this treatment was performed within 7 days after initial injury compared with 110 days when performed ≥8 days after the injury.⁶ Length of hospital stay has also been reported to be reduced by almost 6-fold (11 days vs 62 days) when surgical intervention is employed compared to conservative care.⁵ Single-procedure surgical intervention has also been reported to reduce the length of hospitalization and complications compared with staged procedures.^4,6-10 There is no evidence to support the use of prophylactic antibiotic administration to prevent infection.²²

Algorithm development. Using the findings of the literature review, the authors developed the Lower Extremity Hematoma Algorithm (LEHA) (Figure 2). Implementation of the LEHA begins upon patient presentation. An increased index of suspicion should occur for the patient presenting with any of the risk factors outlined in Table 1. The more risk factors present, the greater the risk for the development of deep dissecting hematoma if appropriate care is not employed. Once the determination has been made that the potential for deep injury exists, focused physical examination of the injured extremity should be performed to evaluate for presence of erythema or edema to the area, open wounds, and active bleeding. The recommended treatment in the algorithm branches here, depending on these physical examination findings. For patients with no open wound and minimal concern for the potential for deep dissecting hematoma formation, the recommended treatment consists of activity limitation, compression, and elevation to help minimize the potential 

for hematoma formation.^7,12,14,15 The patient should follow up with their primary care physician within 48 to 72 hours if their symptoms worsen or do not improve to ensure deep dissecting hematoma is not developing.¹

For patients with an open wound and active bleeding without signs of compromised skin integrity, local evacuation is recommended, ensuring the depth of penetration reaches the tissue plane between the subcutaneous skin and deep fascia. The use of ultrasound or magnetic resonance imaging can assist in ensuring accurate depth of penetration.²³ Hemostasis should be obtained, either with elevation and pressure or through the use of electrocautery or chemical cautery with topical hemostatic agents or dressing impregnated with topical hemostatic agents. If hemostasis is unable to be obtained, immediate referral or consultation to a specialist is recommended for definitive care. Reapproximating of skin flaps should be performed if the tissue appears viable. The use of adhesive wound closure strips is recommended over sutures to minimize further trauma to the skin.^16,24 The patient should be instructed to limit activity and elevate the limb to further minimize the potential for hematoma formation.^7,12,14,15 Referral for reassessment by a wound care specialist in 48 to 72 hours should be placed due to the high risk of complications should hematoma recur.¹ Patients who demonstrate signs of skin compromise, such as skin of dark or dusky coloration, or those with signs and symptoms of deep dissecting hematoma formation as evidenced by localized edema and pain, should be evaluated by a specialist as surgical intervention will likely be required for resolution.

Case study. The patient in this case provided verbal and written consent for the use of their wound photographs and nonidentifying medical information for educational purposes, including publication of a case study. An 85-year-old man initially presented to a local emergency department 3 hours after sustaining a fall from a ladder that resulted in a laceration to the left pretibial region. Medical history was significant for deep venous thrombosis, and he remained on anticoagulant therapy with warfarin. Radiographs of the left leg showed no fracture. The laceration area was irrigated, the avulsed tissue flap was reapproximated with simple, interrupted polypropylene sutures, and a dry dressing was applied. The patient was discharged with oral antibiotics and instructed to follow up with his primary care physician in 10 days for suture removal.

Five days later, the patient returned to the emergency department reporting increased pain, swelling, and redness at the injury site. No acute deep venous thrombosis was found on duplex ultrasound. The patient was discharged with additional antibiotics and again instructed to follow up with his primary care physician for suture removal. The patient presented to the wound clinic 9 days after the date of initial injury for a second opinion due to persistent and worsening pain, edema, and discoloration of the wound and periwound skin. Focused lower extremity physical examination revealed a previously sutured avulsed flap with dark discoloration consistent with tissue necrosis (Figure 3A). The patient was diagnosed with a deep dissecting hematoma based on history and physical examination findings.

The patient was prepared for surgical exploration and evacuation of the deep dissecting hematoma and debridement of all nonviable tissue. A coagulated hematoma was noted immediately upon removal of the previously placed sutures and elevation of the avulsed flap (Figure 3B). Assessment of the area after removal of the coagulated hematoma revealed the presence of nonviable tissue necessitating debridement, which was performed using low-frequency ultrasound (Figure 3C). The resultant soft tissue defect extended down to the muscle and measured 8.2 cm × 6.4 cm × 1.0 cm. (Figure 3D).

Postoperatively, aggressive wound care was initiated, consisting of negative pressure wound therapy for 4 weeks followed by multiple applications of a cellular tissue product to aid in healing. Follow-up evaluation 11 weeks after surgery showed resolution of the wound with minimal scarring (Figure 4).

Misdiagnosis and the delay in care of deep dissecting hematomas leads to prolonged healing times, increased hospital length of stay, and complication potential.^1-4,10 Patients in whom conservative treatment has been employed have a reported 20-day delay before referral to a surgical specialist for definitive care.³ Those for whom the hematoma fails to resolve with conservative treatment have an average 51-day delay before referral for definitive care.³ These delays, which are theorized to be due to lack of provider awareness on the true severity of the injury in this population, demonstrate the benefit of early intervention.^2,15 Symptoms at initial presentation are often mistaken for infection or secondary to other causes of purpura appearance on the skin.² Use of the LEHA may aid in the early identification of patients at risk for development of deep dissecting hematoma, guiding treatment to help prevent patient complications and reduce the need for advanced surgical intervention and hospital admission.¹³

Although a deep dissecting hematoma occurs in the same tissue plane as an internal degloving injury, or Morel-Lavallé lesion, differentiation is easy with use of the LEHA. Internal degloving injuries have a male predominance. Over 80% of these internal degloving injuries are associated with high-energy, blunt force trauma or crush injury, most often occurring in association with pelvic trauma and in the presence of an underlying fracture.²⁵ The most common location for these injuries is around the greater trochanter of the femur.²⁵ This is in opposition to deep dissecting hematomas, which occur more often in older women following minor trauma to the pretibial region.^3-11,18

If the LEHA had been used in as part of the initial evaluation of the patient in the case study, the physician would have noted the patient’s multiple risk factors for deep dissecting hematoma: age ≥80 years, warfarin therapy, fall resulting in blunt trauma and laceration to the pretibial region. Given the initial presentation of the patient with an open wound, the LEHA would have led the physician to locally evacuate any hematoma present and ensure hemostasis was obtained, then approximate the flap by using adhesive wound strips. A compressive dressing should have been applied, and the patient should have been referred to a wound care or surgical specialist for re-evaluation to assess for skin viability. Such a timely and appropriate referral may have enabled the patient to avoid a second visit to the emergency department, an additional round of antibiotics, subsequent surgical intervention, and several weeks of wound care—thus improving the patient’s quality of life and controlling costs.

Limitations of this study include the paucity and poor quality of published literature available on the diagnosis and treatment of deep dissecting hematoma and the lack of validation of the algorithm. Development of the LEHA required the authors to identify similarities in the patient population, mechanisms of injury, and presentations in various case reports and case series to determine how to identify and diagnose patients at high risk for deep dissecting hematoma. Although the literature was of poor quality, the pronounced similarities across the case descriptions allowed for the development of the proposed LEHA. Future studies will be required to validate the algorithm’s effectiveness in guiding early and accurate diagnosis and management of these patients and to ascertain its value in preventing more extensive tissue loss and treatment requirements. High-quality evidence may be hard to implement given the difficulty in performing randomized controlled trials in patients at risk for deep dissecting hematoma development. Case-control cohort studies may be needed to compare differences before implementation of the LEHA.

The LEHA was developed to aid providers in identification and appropriate treatment of patients at risk for developing deep dissecting hematomas of the leg. The patients at greatest risk for negative sequelae are elderly, female, have multiple comorbidities, are on corticosteroids or anticoagulant therapy, and have sustained minor blunt trauma, most often to the pretibial region of the leg. Treatment varies based on physical examination findings. However, all treatment pathways include prompt follow-up for early reassessment. The case example provides an example of how LEHA could be implemented to identify patients at risk for deep dissecting hematomas and expedite the initiation of appropriate and timely treatment, thus containing health care costs and improving patient quality of life.

Windy Cole, DPM, CWSP¹; Stacey Coe, BA, CCRP¹; Sarah Messina, DPM PGY-1²; and Valerie Marmolejo, DPM, MS, CTBS, MWC³

¹Kent State University College of Podiatric Medicine, Kent, OH
²Detroit Medical Center, Detroit, MI
³Certified Medical Writer, Scriptum Medica Medical Writing, University Place, WA

Address all correspondence to: Windy Cole, DPM, CWSP, Kent State University College of Podiatric Medicine, Independence, OH 44131; tel: 216-916-7460;
email: Wcole4@kent.edu