Subcutaneous Hematoma: An Emerging Problem
In the October 2011 issue, LaRosa and Fanelli “Successful Outpatient Treatment of Full-thickness, Necrotic, Lower-extremity Ulcers Caused by Traumatic Hematomas in Anticoagulated Patients” did a fine job describing their care of the four warfarin hematoma and necrosis patients. The use of layered skin substitute and negative pressure wound therapy (NPWT) has become more and more established for these wounds. It might be of interest to know that there is another use for NPWT in less severe cases of skin necrosis and slough associated with subcutaneous hematomas. In fact, if there is no necrosis at all, we have successfully managed these with aspiration (sometimes repeated) and light compression therapy. If there is necrosis, but it does not extend to the edge of the hematoma, then there is a cave-like space with a flue-like opening in the top where the eschar formed. After removing the eschar and the clot, NPWT has been very effective in closing the wound. Care is taken to put the foam in the opening, but not under the skin flaps. This has the virtue of coaxing the skin flaps to adhere down to the fat and, I believe, serve as a form of tissue expansion as well. The NPWT can draw the flap edges toward each other reducing the size of the wound by stretching the flap tissue centripetally from all directions.
In the spirit of preventing hematoma necrosis injuries, we prepared a news bulletin for primary care offices and emergency rooms in the community in order to encourage early referrals to surgeons for evacuation of the blood (Editor’s Note: The bulletin is available online at www.woundsresearch.com). It is our hope to drain the hematomas before the tissue dies and sloughs from the apex of the hematoma; otherwise, we use NPWT.
Frank Welsh, MD