Bone bruise: Difference between revisions

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'''Original Editors - '''Laurien Henau&nbsp;as part of the Vrije Universiteit Brussel's Evidence-based Practice project.


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== Search Strategy  ==
== What is a bone bruise?  ==


Search on PubMed, Science Direct, Web of Knowledge and Pedro with the keywords: “bone bruise”, “bone”, “posttraumatic AND knee”, “subperiosteal bleeding”, “hematoma” and “Magnetic resonance imaging of bones”. <br>The most successful keywords are: “bone bruise”, “MRI of bones” and “posttraumatic AND knee”<br><br>
A bone bruise is a type of bone injury.
* Other examples of bone injuries include [[Stress Fractures|stress fractures]], osteochondral fractures and a variety of different patterns of bone [[Fracture|fractures]].<sub><ref name="p3" /></sub> 
* A bone bruise is characterised by three different kinds of bone injuries including: sub-periosteal hematoma, inter-osseous bruising and a sub-chondral lesion, or a combination of these. <sub><ref name="p6">V. Mandalia, J.H.L. Henson. Traumatic bone bruising – A review article, European Journal of Radiology 2008; 67; 54–61                                                                                                                                        Grades of recommendation A</ref></sub>
* A bone bruise is differentiated from the alternative fracture types in that only some of the trabeculae are broken.<sub><ref name="p9">Janice Polandit, 5 Things You Need to Know About a Bone Bruise, 2011; http://www.livestrong.com/article/5521-need-bone-bruise/                                                                                                                Grades of recommendation F</ref></sub>


== Definition/Description<br> ==
== Clinically Relevant Physiology ==


Bone bruise is one of the four types of fractures that occur in the human body, the others are: stress fractures, osteochondral fractures and bone fractures.<sub>3</sub><br>Bone bruise is a term that contains 3 different kinds of bone injuries: sub-periosteal hematoma, inter-osseous bruising and sub-chondral lesion. <sub>6</sub><br>A bone bruise can be described as a stage before the fracture. <br>When we speak of a real bone fracture it means that all the bone trabeculae of that specific place are fractured. In case of a bone bruise only a few of the trabeculae are broken.<sub>9</sub><br><br>
Bone tissue is a specialised form of connective tissue that is made up of an organic matrix (collagen and glycosaminoglycans) and inorganic minerals (calcium and phosphate). <sub><ref name="p1">L.C. Jungueira and J. Carneiro, “Functional Histology” 2010; 167</ref></sub> An adult human skeleton contains 80% cortical bone and 20% trabecular bone. Both types of bone are composed of osteons. Cortical bone is the solid type of bone and trabecular bone resembles honeycomb which is comprised of a network of trabecular plates and rods. Read more about the histology and physiology of [[Bone|bone here]].


== Clinically Relevant Anatomy  ==
[[File:Bone_1.jpg|frameless|400x400px]][[File:Bone_2.jpg|frameless|520x520px]]


The coccyx, also known as the tailbone, is a small triangular bone that is usually formed by fusion of the four rudimentary coccygeal vertebrae, although in some people there may be one less or one more. The coccygeal vertebra 1 (Co1) may remain separate from the fused group, but with increasing age Co1 often fuses with the sacrum and the remaining coccygeal vertebrae usually fuse to form a single bone. (level of evidence D) <br>The forward movement of coccyx is performed actively by the M. levator ani, and the backward movement of coccyx is passively caused by relaxation of these muscles. The coccyx also provides the site of attachment for the M. gluteus maximus as well as the M. levator ani, which is responsible for voluntary control of bladder and bowel. (level of evidence B) The coccyx does not participate with the other vertebrae in support of body weight when standing, however when sitting it may flex anteriorly, indicating that it’s receiving some weight. ( level of evidence D)i
== Epidemiology ==
The most common cause of bone bruise is trauma however the condition can also be associated with normal stress loading and haemophilia A and B.<sub><ref name="p52">Prof. Dr. S. Van Creveld and Dr. M. Kingma Subperiostal haemorrhage in haemophilia A and B. Ned. T. Geneesk. 105. I. 22. 1961; 1095-1098                                                                                                      Grades of recommendation F</ref></sub>


The coccyx is part of the sacrococcygeal joint, an cartilaginous joint with an IV disc. Fibrocartilage and ligaments join the apex of the sacrum to the base of the coccyx. The anterior and posterior sacrococcygeal ligaments are long strands that reinforce the joint. (level of evidence D) <br>The coccyx is also attached with the margin of the anus by the anococcygeal ligament. (level of evidence D)iii<br><br>
The most commonly affected area is the lower limb. <sub><ref name="p7">Christoph Rangger, Anton Kathrein, Martin C Freund, et al. Bone Bruise of the Knee. Acta Orthop Scand 1998; 69(3) : 291-294.                                                                                                                       Grades of recommendation B</ref></sub>


== Epidemiology /Etiology  ==
Patients with a bone bruise tend to have protracted clinical recovery, with more effusion and a slower return of motion. <sub><ref name="p3" /></sub>


Fracture of the coccyx often arise after a fall on the buttock, most prevalent a fall of the stairs on the tailbone, or by an impact directly applied. (level of evidence D) An especially difficult childbirth occasionally injures the mother’s coccyx. ( level of evidence D) <br><br>
In patients with [[Anterior Cruciate Ligament (ACL)|ACL rupture]] there is an 80% probability of concurrent associated bone bruising at the femoral condyle or tibial plateau.<sub><ref name="p3" /><ref name="p1" /></sub> According to Boks et al. 2007, the presence of bone bruising in these zones is the most important secondary sign in the diagnosis of ACL injury.  


== Characteristics/Clinical Presentation  ==
[[File:Bone_3.jpg|frameless|392x392px]]


1. GENERAL SYMPTOMS<br>General symptoms that appear are (level of evidence D)iv,vii,viii&nbsp;:<br>• Pain that increases in severity when sitting or getting up from a chair<br>• Provoked pain over the tailbone<br>• Bruising or swelling in the tailbone area<br>• Bowel movements and straining are often painful<br>• There are no neurological signs
MRI with white arrow indicating presence of bone bruising in the (a) post-lateral talus area and (b) the caudal tibia epiphysis.<br>


== Clinical Presentation  ==
{| class="wikitable"
!Bone Injury Type
!Characteristics
!Typical Injury Mechanism
|-
|Sub-periosteal hematoma
|A concentrated collection of blood underneath the periosteal of the bone.
|Direct high-force trauma to the bone
|-
|Inter-osseous bruising
|Damage of the bone marrow. The blood supply within the bone is damaged, and this causes internal bleeding.
|Repetitive compressive force on the bone (extreme pressure on regular base).
|-
|Sub-chondral lesion
|Lesion occurs beneath the cartilage layer of a joint.
|Extreme compressive force or rotational mechanism such as testing (shearing force) that literally crushes the cells
Force causes separation of the cartilage (or ligament) and the underlying bone, plus bleeding when the energy of the impact extends into the bone.


 
|}
An important number of people suffer from long lasting pains over the coccyx following trauma (with or without fracture of the coccyx), better known as cocydynia.(level of evidence D)
<br>For the all bone injuries, incidence rates tend to be higher amongst professional athletes and those that run and jump frequently on hard surfaces, for example football and basketball players. <sub><ref name="p3" /><ref name="p6" /></sub>  
 
<br>2. CLINICAL PRESENTATION IN PATIENTS WITH SPINAL CORD INJURY<br>Patients with SCI, suffering from painful symptoms in the low back, gluteal, hip and thigh region, have coccyx fracture with a frequency of 34,6%. Patients who had coccyx fracture have higher pain scores when compared with those who don’t have any fracture, however the difference is only statistical significant regarding Sensory Pain Index (SPI) and total McGill scores.( level of evidence C)
 
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== Differential Diagnosis  ==
 
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== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


1. MEDICAL DIAGNOSIS<br>A plain radiography or MRI is necessary to confirm the diagnose of a coccyx fracture. (level of evidence D)
Although an x-ray should identify whether or not there is a bone fracture, a bone bruise is not able to be diagnosed using [[X-Rays|x-ray]] imaging. The current "gold standard" diagnostic imaging method for bone bruises is the [[MRI Scans|MRI]], in particular  T2-weighted fat-suppressed images or T1-weighted imaging.<sub><ref name="p1" /></sub><br>
 
[[File:Bone_7.jpg|center|frameless|395x395px]]
<br>2. CLINICAL DIAGNOSIS<br>The diagnose is made after rectal examination. (level of evidence D)iv By passing the finger up the rectum and then pressing the bone backwards and forward, the unnatural degree of motion will then be felt. Related to the age and sex of the patient must be remembered that in the female this bone naturally possesses more motion than in the male, and that in youth a degree of motion, that does not exist at a later period of life, is present, allowing the ossification being less complete. However the free motion of the bone is taken as a symptom. (level of evidence D)
[[File:Bone_6.jpg|center|581x581px]]
 
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[[Image:Bone 5.jpg|569x569px|center]]


== Outcome Measures ==
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add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]]) 
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== Examination  ==
[[Image:Bone 9.jpg|left|1126x1126px]]
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== Medical Management <br> ==
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1. COCCYGEOPLASTY<br>By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)
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<br>2. COCCYGECTOMY<br>Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix
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== Physical Therapy Management <br> ==
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add text here <br>
[[Image:Bone 10.jpg|1129x1129px]]


== Key Research  ==
<ref name="p3" /><ref name="p6" /><ref name="p8">Simone S. Boks, Dammis Vroegindeweij, Bart W. Koes, et al. MRI Follow-Up of posttraumatic Bone Bruises of the knee in General Practice. AJR 2007; 189:556–562                                                                  Grades of recommendation B</ref>
== Physical Therapy Management    ==


add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
The treatment of a bone bruise consists of [[RICE]], pain relief and/or anti-inflammatories as prescribed by a medical practitioner and load restriction dependant on the circumstances of the injury. <sub><ref name="p0">The Basics of Bone Bruises;                                                                                  Grades of recommendation F
 
http://bruises.knowingfirstaid.com/permalink.php?article=Bone%20Bruises.txt</ref></sub> The time for the resolution of a bone bruise is variable. Literature suggests that the healing time to completely resolve this injury can take anywhere between three weeks to up to two years after the trauma.<sub><ref name="p3">V. Mandalia, A.J.B. Fogg, R. Chari, J. Murray, A. Beale, J.H.L. Henson. Bone bruising of the knee. Clinical Radiology 2005; 60, 627–636                                                                                                        Grades of recommendation:A</ref><ref name="p6" /></sub>
== Resources <br>  ==
 
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== Clinical Bottom Line  ==
 
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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== References  ==
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MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D<br> YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B<br> MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D<br> HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D<br> MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D<br> TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C<br> RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D<br> LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D<br> MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B<br> EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D<br> DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C<br> COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams &amp; Wilkins, 2008, pag. 144, level of evidence D&nbsp;
[[Category:Vrije Universiteit Brussel Project|Vrije_Universiteit_Brussel_Project]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Primary Contact]]
[[Category:Fractures]]

Latest revision as of 12:55, 3 August 2020

Original Editors - Laurien Henau as part of the Vrije Universiteit Brussel's Evidence-based Practice project.

Top Contributors - Laurien Henau, Claire Knott, Admin, Rik Van der Hoeven, 127.0.0.1, WikiSysop, Kim Jackson, Wanda van Niekerk and Lucinda hampton - . 

What is a bone bruise?[edit | edit source]

A bone bruise is a type of bone injury.

  • Other examples of bone injuries include stress fractures, osteochondral fractures and a variety of different patterns of bone fractures.[1]
  • A bone bruise is characterised by three different kinds of bone injuries including: sub-periosteal hematoma, inter-osseous bruising and a sub-chondral lesion, or a combination of these. [2]
  • A bone bruise is differentiated from the alternative fracture types in that only some of the trabeculae are broken.[3]

Clinically Relevant Physiology[edit | edit source]

Bone tissue is a specialised form of connective tissue that is made up of an organic matrix (collagen and glycosaminoglycans) and inorganic minerals (calcium and phosphate). [4] An adult human skeleton contains 80% cortical bone and 20% trabecular bone. Both types of bone are composed of osteons. Cortical bone is the solid type of bone and trabecular bone resembles honeycomb which is comprised of a network of trabecular plates and rods. Read more about the histology and physiology of bone here.

Bone 1.jpgBone 2.jpg

Epidemiology[edit | edit source]

The most common cause of bone bruise is trauma however the condition can also be associated with normal stress loading and haemophilia A and B.[5]

The most commonly affected area is the lower limb. [6]

Patients with a bone bruise tend to have protracted clinical recovery, with more effusion and a slower return of motion. [1]

In patients with ACL rupture there is an 80% probability of concurrent associated bone bruising at the femoral condyle or tibial plateau.[1][4] According to Boks et al. 2007, the presence of bone bruising in these zones is the most important secondary sign in the diagnosis of ACL injury.

Bone 3.jpg

MRI with white arrow indicating presence of bone bruising in the (a) post-lateral talus area and (b) the caudal tibia epiphysis.

Clinical Presentation[edit | edit source]

Bone Injury Type Characteristics Typical Injury Mechanism
Sub-periosteal hematoma A concentrated collection of blood underneath the periosteal of the bone. Direct high-force trauma to the bone
Inter-osseous bruising Damage of the bone marrow. The blood supply within the bone is damaged, and this causes internal bleeding. Repetitive compressive force on the bone (extreme pressure on regular base).
Sub-chondral lesion Lesion occurs beneath the cartilage layer of a joint. Extreme compressive force or rotational mechanism such as testing (shearing force) that literally crushes the cells

Force causes separation of the cartilage (or ligament) and the underlying bone, plus bleeding when the energy of the impact extends into the bone.


For the all bone injuries, incidence rates tend to be higher amongst professional athletes and those that run and jump frequently on hard surfaces, for example football and basketball players. [1][2]

Diagnostic Procedures[edit | edit source]

Although an x-ray should identify whether or not there is a bone fracture, a bone bruise is not able to be diagnosed using x-ray imaging. The current "gold standard" diagnostic imaging method for bone bruises is the MRI, in particular T2-weighted fat-suppressed images or T1-weighted imaging.[4]

Bone 7.jpg
Bone 6.jpg
Bone 5.jpg



Bone 9.jpg








Bone 10.jpg

[1][2][7]

Physical Therapy Management[edit | edit source]

The treatment of a bone bruise consists of RICE, pain relief and/or anti-inflammatories as prescribed by a medical practitioner and load restriction dependant on the circumstances of the injury. [8] The time for the resolution of a bone bruise is variable. Literature suggests that the healing time to completely resolve this injury can take anywhere between three weeks to up to two years after the trauma.[1][2]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 V. Mandalia, A.J.B. Fogg, R. Chari, J. Murray, A. Beale, J.H.L. Henson. Bone bruising of the knee. Clinical Radiology 2005; 60, 627–636 Grades of recommendation:A
  2. ↑ 2.0 2.1 2.2 2.3 V. Mandalia, J.H.L. Henson. Traumatic bone bruising – A review article, European Journal of Radiology 2008; 67; 54–61 Grades of recommendation A
  3. ↑ Janice Polandit, 5 Things You Need to Know About a Bone Bruise, 2011; http://www.livestrong.com/article/5521-need-bone-bruise/ Grades of recommendation F
  4. ↑ 4.0 4.1 4.2 L.C. Jungueira and J. Carneiro, “Functional Histology” 2010; 167
  5. ↑ Prof. Dr. S. Van Creveld and Dr. M. Kingma Subperiostal haemorrhage in haemophilia A and B. Ned. T. Geneesk. 105. I. 22. 1961; 1095-1098 Grades of recommendation F
  6. ↑ Christoph Rangger, Anton Kathrein, Martin C Freund, et al. Bone Bruise of the Knee. Acta Orthop Scand 1998; 69(3) : 291-294. Grades of recommendation B
  7. ↑ Simone S. Boks, Dammis Vroegindeweij, Bart W. Koes, et al. MRI Follow-Up of posttraumatic Bone Bruises of the knee in General Practice. AJR 2007; 189:556–562 Grades of recommendation B
  8. ↑ The Basics of Bone Bruises; Grades of recommendation F http://bruises.knowingfirstaid.com/permalink.php?article=Bone%20Bruises.txt


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