Haematoma (bruise): causes, symptoms, treatment

A haematoma is the medical term for a bruise, often referred to simply as a „blue mark“. It occurs when small blood vessels (capillaries, veins or, more rarely, arteries) are damaged by an injury and blood leaks into the surrounding tissue, a body cavity or under the skin. This leaked blood undergoes a clotting process and then becomes visible to us as a change in colour and often as swelling – the typical ‘bruise’.

How does a haematoma develop? Causes and occurrence

The most common cause of haematomas and bruising is external force, such as a minor injury or a more serious one:

• A knock or blow (e.g. against a piece of furniture)
• A fall (e.g. whilst playing sport or going about daily life)
• A bruise or contusion

Such incidents cause damage to the tiny blood vessels under the skin or in deeper layers of tissue. This is how bruises form.

Other possible causes and occurrences:

After surgery: Haematomas are a very common and usually normal side effect following surgical procedures, as these inevitably involve the severing of tissue and small blood vessels. This is also the case in the field of cosmetic surgery.

Taking medication: Certain medicines, particularly blood thinners (anticoagulants such as Marcumar®, heparin or acetylsalicylic acid/ASA), increase the likelihood of bleeding and, consequently, of haematoma formation, often even in response to minor incidents.

Diseases: In rare cases, certain medical conditions that interfere with blood clotting (e.g. haemophilia, a shortage of blood platelets) or make the blood vessel walls more fragile can also lead to an increased tendency to develop bruises. This can be a reason for frequent bruising.

Spontaneous haematomas: In some cases, small haematomas can occur even without any apparent external cause, particularly in people with very fragile blood vessels or a tendency towards weak connective tissue.

Age: As we get older, the skin becomes thinner and the supporting connective tissue weakens, which can make us more prone to bruising.

In principle, haematomas can occur anywhere on and within the body where there are blood vessels – from the surface of the skin right down to deep muscle layers or organs. Sometimes, deeper bruises only become visible after several days.

What are the symptoms of a haematoma?

The typical signs of a superficial haematoma – in other words, a classic bruise – are:

• Skin discolouration: This is the most noticeable symptom. The colour changes over time and often displays several different colours at once.
• Swelling: The affected area may swell as a result of the blood that has seeped out and the body’s inflammatory response.
• Pain: Haematomas are often tender to the touch or cause spontaneous pain, particularly in the first few days. The pain and the extent of the haematoma depend on its size and location.
• Overheating: The affected area may feel warmer than the surrounding area.
• Functional limitation: In the case of larger haematomas, particularly if a haematoma is located near a joint, mobility may be restricted.

The severity of the symptoms depends on the location and size of the haematoma, as well as on the severity of the original injury.

The typical colour progression of a haematoma: from blue to yellow

The discolouration of a haematoma, which often turns blue, is a fascinating process that reflects the breakdown of the blood pigment haemoglobin in the tissue until the haematoma disappears completely:

1. Days 0–2 (red to dark red/blue) Immediately after the injury, the blood that has leaked out is still rich in oxygen and appears reddish. The blood clots quickly and loses oxygen, causing its colour to change to dark red, blue, deep violet or almost black.
2. Days 3–5 (blue-black to dark green) The body begins to break down haemoglobin. One of the breakdown products is biliverdin (a bile pigment), which has a greenish colour.
3. Days 5–10 (green to yellow-brown) Biliverdin is further broken down into bilirubin (also a bile pigment), which results in a yellowish-brown colour. At this stage, the stain may display several colours at once.
4. Days 10–14+ (light yellow to fading) The bilirubin is gradually eliminated; the colour fades and eventually disappears completely, until the normal skin colour is restored. The body has completely broken down the blood and the blood residues.

What types of haematoma are there?

Medical professionals classify haematomas according to their location and depth:

• Subcutaneous haematoma: The classic „bruise“, located just beneath the skin (in the subcutis), where the skin is still intact. This is the most common form.
• Intramuscular haematoma: Haemorrhage within a muscle. This can be more painful and take longer to heal.
• Periostal haematoma: A bruise on the periosteum, e.g. commonly on the shin following a blow.
• Haematomas in body cavities or organs (as well as internal haematomas): Far more serious are haemorrhages within body cavities (e.g. joint effusion/haemarthrosis, accumulation of blood in the chest cavity/haemothorax) or within organs. Intracranial haematomas (haematomas in the brain), such as epidural or subdural haematomas, are particularly dangerous as they can exert pressure on the brain and require immediate medical attention, since the blood cannot drain out. Such internal haematomas are not always immediately apparent.
• Specific forms: Examples include a monocle haematoma (a bruise around one eye) or a spectacles haematoma (affecting both eyes), which may indicate a skull base fracture. A bruise under a fingernail or toenail (subungual haematoma) is also a type of haematoma.

To the untrained eye, it is usually only the subcutaneous haematoma that is directly visible.

How is a haematoma diagnosed?

A superficial haematoma is usually identified by a doctor through visual examination, based on the typical discolouration and swelling of the skin. The doctor will also ask about the circumstances of the accident or possible causes (medical history).

If deep-seated or larger haematomas are suspected, particularly where the cause is unclear or complications are suspected, imaging techniques may be used:

• Ultrasound (sonography): It can clearly show the extent and location of a haematoma.
• Magnetic resonance imaging (MRI) or computed tomography (CT): These are used when internal bleeding or haematomas in the head are suspected.

How is a haematoma treated?

Most minor, superficial haematomas heal on their own without causing any lasting effects and do not require any specific medical treatment. However, there are measures that can aid the healing process and reduce symptoms such as pain and the spread of the bruise:

The PECH rule as an immediate first-aid measure

Immediately after an injury that could lead to a haematoma, applying the RICE principle helps to seal the damaged blood vessels and reduce blood flow:

1. P – Break Rest the affected part of the body and avoid putting any further strain on it.
2. E – Ice cream Cool the area for about 15–20 minutes using a cold compress, an ice pack (wrapped in a cloth to prevent frostbite!) or cold water. The cold causes the blood vessels to constrict, which reduces the amount of blood leaking out and minimises the swelling and the size of the bruise.
3. C – Compression A light pressure bandage (elastic bandage) can also help to limit bleeding into the tissue and reduce swelling. Take care not to apply the bandage too tightly, so as not to restrict blood circulation.
4. H – Raise off the ground Raising the affected part of the body (above heart level) facilitates the drainage of blood and lymph fluid, thereby helping to reduce swelling.

Supportive ointments and home remedies

Various ointments and gels available from the chemist can aid the healing process and relieve symptoms:

• Ointments containing heparin: Heparin has an anticoagulant effect and can help speed up the resolution of a bruise and reduce swelling.
• Arnica ointments or tinctures: Arnica is said to have anti-inflammatory and decongestant properties.
• Plant extracts: Ointments containing comfrey or horse chestnut extract can also provide relief.

When should you see a doctor about a haematoma?

Although most haematomas are harmless, there are situations in which it is advisable, or even necessary, to see a doctor in order to avoid complications:

• Very large or rapidly enlarging haematomas: Particularly when they arise without good reason.
• Severe, throbbing pain: Those who do not respond to standard painkillers.
• Significant swelling and restricted movement: Particularly in the area of joints. An untreated joint effusion (haemarthrosis) can, in the long term, contribute to the development of osteoarthritis, for example.
• Bruises on the head, around the eyes, on the neck or in the genital area: These may indicate more serious injuries or lead to complications.
• Additional symptoms: Such as a fever, feeling very unwell, nausea, vomiting, impaired consciousness or signs of paralysis (particularly following head injuries).
• Bruises with no apparent cause, or if you notice that you bruise easily: If you frequently develop bruises or get them for no apparent reason, you should see a doctor to rule out any clotting disorders or other medical conditions.
• Suspected additional injury: Such as, for example, a broken bone or a ligament injury.
• If the haematoma becomes infected: Symptoms include severe redness, warmth, throbbing pain and, in some cases, the formation of pus.
• If you are taking blood-thinning medication (e.g. Marcumar®) and develop a larger haematoma.

Aftercare: What should you bear in mind following a haematoma?

Follow-up care for an uncomplicated haematoma does not usually require any specific measures:

• Patience: Give your body time to absorb the bruise. Depending on its location, size and depth, it may take anywhere from a few days to several weeks for the haematoma to disappear completely. A bruise often fades significantly within two weeks.
• Preservation: Avoid putting the affected area under heavy strain or subjecting it to further impact during the first few days.
• Observation: Watch out for signs of a worsening condition or infection (see „When to see a doctor?“).
• Gentle mobilisation: Once the acute pain has subsided, gentle exercise can help to stimulate metabolism in the affected area and promote the breakdown of blood residues.

In the case of haematomas requiring medical treatment or those that are particularly large, your doctor will give you specific instructions on aftercare.

Bruising following cosmetic procedures: What is normal?

Following cosmetic surgery procedures, such as liposuction, breast augmentation or a facelift, bruising and swelling are very common and are usually a normal part of the healing process. The extent of these symptoms can vary depending on the type and extent of the procedure, the individual’s predisposition and the surgical technique used.

Your surgeon will explain in detail before the procedure any side effects you can expect, such as bruising. It is important to note that:

• Please follow the post-operative instructions carefully: These usually include applying cold compresses, elevating the affected area, wearing compression garments and taking prescribed medication.
• Attend regular check-ups: Your doctor will monitor your recovery.
• Please report any irregularities: If bruises become unusually large, are extremely painful, the swelling increases significantly, or you notice any signs of infection, contact your doctor immediately.

Although bruises following cosmetic surgery may look unsightly, they are usually temporary. Good aftercare is crucial for achieving the best possible result and can help the bruises to fade more quickly.