Bone Bruise

What is a bone bruise?

A blunt injury to the bone results in collection of blood in the bone and gives rise to a blackish bruise that is called as bone bruise. These bruises are most common around the bony prominences like the knee and the ankle joint. The commonest cause of a bone bruise is contusion to the bone which can be caused by compression or blunt injury on the bone. They are associated with joint pain and inflammation. The diagnosis of bone bruise is purely clinical and they cannot be picked up on X-ray or MRI. A bone bruise may take few months to heal back to normal.

Another condition that is often confused with bone bruise is subperiosteal heamatoma. The aetiology is mostly an injury following which, there is a collection of blood between the bone and the periosteum. The injury to the bone leads to swelling around the affected joint which is called as oedema of the bone marrow. Oedema can be picked up by an MRI where the normal density of the bone will appear changed with or without collection of fluid in the bone.

Medical definition

Bone bruise is defined as the localized blood collection inside a bone which may be associated with an internal fracture in the spongy part of the bone.The cortical layer on the outside remains normal and intact. The cause is usually an acute injury or trauma.

Deep Bone Bruise is an injury and bleed in the medullary part of the bone and hence it is classified as intraosseous bleed. On the other hand subperiosteal heamatoma is a bone bruise that is superficial in nature.

Types of bone bruise

There are two types of bone bruises. The classification is based on the type of injury and location of the bleeding.

(1)Intraosseous Bleeding:

Intra means within and the term os is used for bone so it denotes bleeding occurring within the bone. This type of bleeding is commonly diagnosed as a bone bruise.

Causes of Bone Bruise

• Acute trauma affecting the person and involving the joint
• Fall or blow directly onto the joint
• Excessive impact or friction between the two bones present in a joint
• Sports persons are very prone to these bruises. The sports like football, basketball, hockey etc have maximum joint movements with speed and so the impact of the injury is greater.
• Martial arts personnel
• Atheletes who run on hard grounds
• Car accidents
• Fall from great heights.

Signs and Symptoms

• Affected joint is swollen and inflamed
• Skin has bruises which are not due to bleeding beneath the skin but a result of internal bleeding in the bone.
• Injury to the muscles and tendons of the joints
• Joint pain which lasts even when the bruise has healed

Common Locations of Bone Bruises

Bone bruises are more common on the bony prominences of the body. The common sites where these bruises are seen are:

• Fibula bone in the leg
• Calcaneum bone in the heel. It presents as heel pain along with a bruise
• Hip bone-head of femur
• Scapula-shoulder bone
• Pubic bone
• Elbow
• Bones of the wrist
• Spinal vertebrae
• Head of the humerus-long bone of the arm
• Patella which is a small bone present in front of the knee joint.

Types of Bone Bruises

(a)Ankle Bone Bruise:

Source: Physio-pedia.com

Bone bruises are common in the ankle region especially in the lower ends of the tibia or the talus bone. It is seen after ankle sprain when the person lands after an injury on the ankle with the foot twisted inwards. The weight of the body falls on the ankle joint and leads to a bruise which can take upto 3 months to heal. The pain heals much faster. The dense picture on an MRI of the ankle can be seen for upto one year after the fall.

(b)Knee Bone Bruise:

Source: Physio-pedia.com

Causes: Bone bruises in and around the knee joint are very common in atheletes. They occur when a person who is at a great speed, suddenly stops or lands or a hard surface. This leads to a severe blow on the knee joint, femur (thigh bone) and the tibia (shin bone). The sites of bone bruises are the upper tibia, the lateral epicondyle of femur. The intensity of the injury or fall can also lead to rupture of the ligaments surrounding the knee joint like the anterior and medial collateral ligament.

Symptoms: The main symptoms is pain and swelling of the knee joint which due to the injury of the ligaments and muscles. Bone bruise is present in this case but is not the cause of the pain.

Prognosis: After a knee joint bone bruise, the recovery time for atheletes is usually 6 months especially if the anterior cruciate ligament is torn. The bone bruise tends to heal within 60 days whereas the ligament will take much longer to heal.

(c)Types of Bone Bruises Based on MRI Findings

Source: PubMed Central

(i)Reticular: Reticular type of bone bruises are those that happen in the medulla of the bone or the spongy inner layer. The bruise does not reach the surface of the joint and is generally mild in intensity. The minor cracks are seen only in the medulla where as the cortical portion remains intact.

(ii)Geographic: This type of bone bruise is comparatively bigger in size and more dense as compared to reticular bruise. The location is closer to cortex of the bone. The bruise will encroach into the joint space on MRI.

Source: PubMed Central Source: Physio-pedia.com

If the geographic type of bruise is in connection with the joint then it is diagnosed as osteochondral fracture. This type of fracture involves the cartilage and takes few years to completely heal.

(iii)Impaction: In a joint cavity, if both the bones rub against each other, the articular surface tends to get damaged resulting in a bone bruise on both the surfaces. This condition is called as a kissing contusion where the two bruises are seen one on top of the other separated by a white lines that is the bone.

Source: Orthopaedicsone

Diagnosis

• Radiological investigations are very useful in detecting the cause of the bone bruise.
• X-ray is used to diagnose a fracture in the bone. However an intraosseous bleed cannot be picked up on an X-ray. Similarly a CT scan also cannot detect the bleeding in the bone that has caused the bone bruise.
• MRI-magnetic resonance imaging can be used in detecting the bone bruises inside the bone as changes in the bone density can be noted. The detection of a bone bruise with the help of an MRI can be done only 30 hours after the injury has taken place.
• The results will vary depending on the type of the MRI. T1 weighted method of MRI will show the bruise in the form of a decrease in bone intensity. A T2 weighted scan or a fat suppressed type of MRI will show increased intensity.

Differential Diagnosis

There are some medical conditions which present with similar symptoms as bone bruise. It is very important to differentiate these conditions with the help of specific symptoms. The differential diagnosis of bone bruise are-

• Subchondral cyst
• Periarticular infection of the bone
• Osteoarthritis
• Stress fractures as a result of repeated trauma
• Osteochondritis dissecans
• Cancer of the bone
• Lymphoma, multiple myeloma of the bone.
• Inflammation of the bone or joint (reactive arthritis, bacterial arthritis or osteomyelitis)
• Pagets disease
• Intraosseous cyst
• Red marrow hyperplasia
• Bone marrow lesion syndrome
• Gauchers disease
• Osteopenia that is weak bones in malnourished individuals
• Algodystrophy
• Haematoma within the bone in people with bleeding disorders

Treatment

(a)The affected leg or part which has suffered the injury should be kept elevated and immobile to prevent further damage.

(b)Ice packs should be applied to the part to reduce the pain and inflammation. This can be done by wrapping ice packs in a towel got get greater joint coverage.

(c)Rest of the affected joint or leg is very essential to prevent further damage.

(d)Support the affected leg with the help of a splint or walking stick/crutches.

(e)Pain reducing medicines and anti inflammatory drugs are also fairly effective.

(f)Once the injury is better, the doctor may advice physiotherapy sessions to ensure that the joint remains mobile and to prevent stiffness.

(g)Smoking should be strictly avoided, as nicotine in the blood tends to prolong the process of healing.

Recovery and Healing Time

The healing time is measured as the time taken for the bone bruise to completely disappear. In most cases, it can take a few months for the bruise to go away. In knee joint bone bruises, this time is upto two months whereas ankle bruises may take even twelve months to completely go away. Reticular bruises tend to heal the fastest. Impaction and geographic bruises take moderate amount of time. The time taken to heal gets more in older individuals or those people who already have osteoarthritis of the joint.

The time taken by the individual to get back to normal activities is called as recovery time. This time is usually shorter than healing time. Once the injury heals, the person can resume his normal activities. This takes only a few months. The presence of underlying joint damage and degeneration can make the healing time longer. For knee joint bruises it is six months and only three months for ankle bruises.

Source: Physio-pedia

Complications

The known complications that are associated with intraosseous bleed are joint stiffness, post trauma osteoarthritis. This is more common after a geographic bruise. In some cases, there is avascular necrosis of the bone as the blood supply to the bone is affected. It leads to chronic pain and the only treatment is surgery.

(2) Subperiosteal Haematoma:

A condition where the blood collects inbetween the cortical bone and the periosteum is called as subperiosteal haematoma. The following are the common sites where this hematoma may occur:

1. Eye: Subperiosteal heamatoma can occur in the roof of the orbit in the eye after a trauma or injury. The other causes are severe vomiting, weightlifting, scuba diving, sinusitis or after labour. It is seen more often in males. Spontaneous bleeding in the eye can also happen in patients with bleeding disorders like leukaemia, haemophilia and scurvy.

The diagnosis is done on the basis of symptoms like blurring of vision and outward protrusion of the eyeball. The vision trouble increases with each passing day.

Treatment is done with antibiotics, aspiration, steroids or surgery.

2. ShinBone: Direct injury to the shin bone in atheletes and sports persons is the commonest cause of superiosteal hematoma in the shin bone. Sports like football and martial arts are more often associated with such injuries.

Symptoms are pain and a bluish black skin bruise. There may be joint tenderness and swelling. The pain will last for a few days to few weeks.

Diagnosis can be done by tests like X-ray, ultrasound or Ct scan.

Treatment is primarily rest and elevation of affected leg. Weight bearing is not allowed on the injured leg. Ice packs are useful in reducing the swelling.

Complication associated with subperiosteal haematoma is calcification of the blood clot and formation of bone tissue around it.

3. Skull: Subperiosteal heamatoma can occur in the skull especially in newborn babies when forceps delivery is carried out. In older people it is rare and can be seen if the person has a bleeding dyscracia.

Symptoms are skin bruises and bulging anywhere in the scalp region due to collection of blood beneath the bone. The clot will resolve on its own but if the size is big and it fails to get reabsorbed, then surgical removal of the clot has to be done. The complication that can occur is that the clot may get ossified with bone tissue.

4. Other sites a periosteal hematoma can occur are:

• Coccyx or tailbone

Source: Wikidot

• Iliac bone and pubic bone after a blunt injury to the pelvic region.
• Clavicle-collar bone
• Sternum-breastbone

Bone marrow oedema

The diagnosis of bone marrow oedema is done on the basis of MRI findings that show changes in the density of the bone. The causes could be bone bruise, inflammation, oedema or fluid collection. The following are the types of bone marrow oedema.

(a)Non traumatic Oedema

The causes and sites of marrow oedema that are not due to any kind of trauma are-

Foot: Bone marrow oedema in the ankle and the foot can occur in young individuals and give rise to pain in the foot or the ankle without any identifiable cause.

Wrist: Rheumatoid arthritis causes oedema of the bone marrow and affects the smaller joints of the body. Wrist and joints of the hand are involved before the patient tests positive for rheumatoid factor.

Hip: The commonest cause of oedema in the hip bone is avascular necrosis of the neck of femur. The symptoms are pain that is severe and felt in the upper thigh without any history of injury or trauma.

During the last trimester of pregnancy, many ladies suffer from a transient osteoporosis of the hip which gives rise to pain in the hip and the thigh. The condition resolves after the baby is born.

Spine: Spinal arthritis or spondyloarthritis causes bone marrow oedema which is the diagnostic feature on an MRI

(b) Reactive Oedema

Presence of a tumour or growth leads to inflammatory changes in the bone. These changes are seen in MRI and are diagnosed as reactive oedema of the bone marrow. The causes of this type of bone marrow oedema are:

• Ostetis
• Osteoporosis
• Bone tumours-benign and malignant
• Osteonecrosis
• Ganglion cyst
• Regional pain syndrome

SOME DEFINITIONS RELATED TO BONE BRUISE

Bone Fracture is a condition where the outer cortical layer and the inner medullary layer are affected. Depending on the severity of the injury, the bone may be broken and the broken parts may be separated with a gap in the middle. This can be picked up on a digital X-ray

Stress Fracture occurs when there is repeated and constant trauma to the bone. Here the medullary and the cortical portions of the bone will be broken but the broken pieces do not separate from each other. This is common in older females when there is existing bone weakness due to osteoporosis. The diagnosis can be done by an X-ray or MRI.

Occult Bone Fracture is diagnosed when the inner and outer layers of the bone are broken but the fracture occurs in such a way that the line of the fracture is non identifiable and thin. The cartilage also may be involved. Diagnosis by an X-ray is often difficult and higher investigations like MRI may be required.

Osteochondral Fracture: If the hairline bone fracture affects the cartilage and forms a connection between the joint and the bone bruise then it is diagnosed as an osteochondral fracture.

Bone Bruise is a condition where the cortical part of the bone is intact and the inner medullary part is broken. The detection of a bone bruise requires a CT scan or MRI.