Vascular trauma without adequate hemostasis can lead to the accumulation of blood within surrounding soft tissue. The extravasated blood organizes and is consequently known as a hematoma . In smaller compartments of the body, such as the hand, hematomas are self-limiting. The volumetric pressure from accumulating fluid eventually tamponades the leaking vessel and achieves hemostasis. Within 24-48 hours, the blood coagulates and develops into a gelatinous form that is broken down and slowly resorbed . Large hematomas may take weeks to months to fully resorb, and while self-limiting in the hand, are not without significant patient discomfort, and sequela.
An 87-year-old female with a past medical history of atrial fibrillation, on warfarin, congestive heart failure, on aspirin, and dementia – admitted for urinary tract infection and altered mental status. Noted to have a large left dorsal hand hematoma (Figure 1) on hospital day three. Multiple venipuncture access sites through the dorsum of the left hand during admission.
Mentation at baseline following treatment of urinary tract infection with intravenous antiobiotics. Endorsing severe pain and discomfort over dorsum of left hand. Extension range of motion limited by pain and swelling. Neurovascularly intact. Plain films negative for foreign bodies, or fractures. Eschar noted over the ulnar aspect of extensor zone VI, which may indicate recent hand trauma. Patient denies trauma, however was altered prior to admission.
Mechanism of Injury
Hand injuries are often the result of blunt, or penetrating trauma . Mild bruising and discoloration are commonly present on physical exam as a result of disrupted capillaries at the site of injury. When larger vessels are injured, patient’s often present with associated edema and ecchymosis. In comparison to the volar surface of the hand, the dorsum is characterized by thinner, more fragile skin, and less robust subcutaneous tissue . Consequently, injuries the dorsum of the hand can result in a higher incidence of underlying vascular injury and hematomas.
In an outpatient/emergency department setting, dorsal hand hematomas typically present as a result of blunt/penetrating trauma, crush injuries, or friction injuries. On occasion, a clinician may be consulted to evaluate a dorsal hand hematoma in an inpatient setting. In contrast to common outpatient injuries, inpatient dorsal hand hematomas can often be iatrogenic from venipuncture blood draws or intravenous access. These penetrating injuries are often a result from backwalling the vein during cannulation, and/or failing to remove the tourniquet upon completion . When the tourniquet remains in place, an upstream occlusion prevents adequate venous return, increasing local hydrostatic pressure and the potential for extravasation. Though the majority of venipunctures are appropriately clotted, poor venous hemostasis is insidious in nature and can lead to a significant hematoma when unnoticed.
Additional factors that may contribute to inpatient/outpatient dorsal hand hematomas include medical comorbidities, such as hypertension, EtOH use, congenital coagulopathies, anticoagulation/antiplatelet status, and patient mental status. While current literature evaluates the relationship between these comorbidities and hematomas in cutaneous surgery, these principals can still be applied to traumatic dorsal hand hematomas. Poorly controlled hypertension increases hydrostatic pressure across vessel walls, which may lead to inadequate clot formation following vascular trauma. Current perioperative guidelines in cutaneous surgery demonstrate minimal hematoma risk with a blood pressure of 180 mmHg systolic or 100 mmHg diastolic or lower . Elderly patients are often on anticoagulation or antiplatelet medication(s). An otherwise clinically insignificant vascular injury to the dorsum of the hand may result in the development of a large hematoma in this population. Literature for cutaneous surgery demonstrates a low overall risk of hematoma formation with anticoagulation/antiplatelet use (1.4%) . However, when compared to patients not taking anticoagulation/antiplatelet medication, hematoma risk increases 2x in patients on Warfarin, 6.7x in patients on novel oral anticoagulation, and 3-10x for patients on both antiplatelet and anticoagulation medications . Aspirin has not been shown to cause a statistically, or clinically significant increase in bleeding/hematoma risk in cutaneous surgery [4,6]. In addition to congenital and medication induced coagulopathies, altered mental status from substance abuse, or cognitive impairment may contribute to worsening dorsal hand hematomas. The gradual development of a hematoma may go unnoticed in altered patients who are able to adequate voice discomfort, or perceive pain. Often times these injuries are discovered by medical staff once the hematoma is of considerable since.
A standardized hand exam should be performed to assess for neurovascular, ligamentous, or tendinous injuries. A 3-view x-ray should be obtained with any hand trauma to assess for foreign bodies, or osseous injuries.
Mild/Moderate Hematoma: Ecchymotic skin, with mild to moderate edema may be treated with conservative management. The patient should be assessed for degree of discomfort, hand range of motion, and appearance of skin. If the dorsal hand skin does not appear threatened, or markedly turgid, the patient’s hand should be elevated to reduce edema and promote resorption. Direct pressure by the provider should be applied to the dorsum of the hand for at least 5 minutes to gain adequate hemostasis in the setting of an acute bleed. A compression wrap may be applied using an ace bandage, with care not to apply the dressing too tight, or immobilize joints that may result in future stiffness. Splinting of the hand in the safety position may also be useful in reduce swelling. Using a volar slab, splint the wrist in 30 degrees flexion, metacarpophalangeal joints in 90 degrees flexion, and proximal/distal interphalangeal joints in full extension. Again, care must be taken to avoid joint immobilization for extended periods of time to avoid stiffness. The splint should be removed daily to evaluate the hand. Holding non-steroidal anti-inflammatory, anticoagulation or antiplatelet is not indicated.
Severe Hematoma: Large hematomas are often painful with noticeable discomfort. They are characterized by substantial ecchymosis, edema, and markedly turgid skin. Volumetric pressure from subcutaneous fluid applies force to the tissue and skin above. If left untreated, the overlying skin becomes ischemic, leading to necrosis and tissue breakdown. In doing so, the hematoma is spontaneously evacuated, however, the patient is left with a large soft tissue deficit that may expose extensor tendon and neurovasculature. Thus, severe hematomas necessitate evacuation from the oncall hand surgeon, which can be performed beside under local anesthesia.
Supplies: 1% lidocaine with 1:100,000 epinephrine, 18 gauge blunt needle, 10cc syringe, 23 gauge needle, sterile drapes, ChloraPrep/Betadine/Solution to prep skin, 11 blade scalpel, forcep/kelly clamp, 60cc syringe, 500cc normal saline/sterile water, basin, packing gauze, 4×4 gauze, ABD pads, Kerlix wrap, and tape.
- Palpate the dorsal hand hematoma to identify the area of maximal fluctuance.
- Once identified, the surgeon should plan their incision over this area. Be mindful that a small incision 2-3cm is often all that is required for evacuation (Figure 2).
- Using a 23 gauge needle infiltrate your planned incision line over the point of maximal fluctuance with 1% lidocaine with 1:100,000 epinephrine.
- Prep and drape the site in the standard fashion to maximize sterility
- Using an 11 blade, make a small incision through dermis to expose the dorsal compartment. It is important to remember that the skin is often friable. Care must be taken to avoid a deeper cut than intended.
- Once a small incision is made, a forceps or kelly clamp can be inserted along the direction of the incision. Using the 11 blade, complete your incision along the direction of the forcep, protecting the extensor tendons beneath.
- If needed, the incision can be enlarged to complete the evacuation.
- Using manual compression, evacuate the hematoma/blood. A kelly clamp can be advanced throughout the dorsum of the hand to help break-up organized collections. The tips of the Kelly clamp should be oriented superiorly to avoid catching extensor tendon during exploration.
- Using a 60cc syringe, irrigate the dorsal hand wound thoroughly using normal saline or sterile water.
- Pack the incision with packing gauze. Place 4×4 gauze, or an ABD pad over the incision and wrap with Kerlix to reinforce.
- Elevate the hand and change packing daily.
- Do NOT close wound. The skin is often friable, and the wound is at an increased risk for infection. Allow for wound to heal by secondary intention.
- A standardized hand exam and radiographs should be obtained for all dorsal hand hematomas, even if mechanism, and extent of the injury appears obvious.
- Mild/moderate dorsal hand hematomas can be treated with conservative management (e.g. hand elevation, compression wrap, and/or splinting)
- Severe dorsal hand hematomas should be evacuated at bedside to ameliorate future wound break down and sequela.
- Adani R. Dorsal hand coverage. BMC Proc. 2015;9(Suppl 3):A59. Published 2015 May 19. doi:10.1186/1753-6561-9-S3-A59
- Bunick CG, Aasi SZ. Hemorrhagic complications in dermatologic surgery. Dermatol Ther. 2011;24(6):537-550. doi:10.1111/j.1529-8019.2012.01454.x
- CLSI. Collection of Diagnostic Venous Blood Specimens. 7th ed. CLSI standard GP41. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
- Eilers RE Jr, Goldenberg A, Cowan NL, Basu P, Brian Jiang SI. A Retrospective Assessment of Postoperative Bleeding Complications in Anticoagulated Patients Following Mohs Micrographic Surgery. Dermatol Surg. 2018;44(4):504-511. doi:10.1097/DSS.0000000000001394
- Maroukis BL, Chung KC, MacEachern M, Mahmoudi E. Hand Trauma Care in the United States: A Literature Review. Plast Reconstr Surg. 2016;137(1):100e-111e. doi:10.1097/PRS.0000000000001879
- Nast A, Ernst H, Rosumeck S, Erdmann R, Jacobs A, Sporbeck B. Risk of complications due to anticoagulation during dermatosurgical procedures: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2014;28(12):1603-1609. doi:10.1111/jdv.12611