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Bone Bruise or Contusion

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Published: December 4, 2013
Last reviewed: June 16, 2016

What is a bone bruise?

A bone bruise is a localized collection of blood within the bone caused by a bone contusion 1,6.

  • Most common in the knee and ankle
  • Joint pain, swelling
  • Not visible on X-ray; an MRI required for diagnosis
  • Treatment with splints and analgesics
  • Recovery time: several months

What is a bone contusion?

A bone contusion is any compression injury of the bone, which is usually associated with a bone bruise.

What is subperiosteal hematoma?

Subperiosteal hematoma is a collection of blood between the periosteum and the bone, which is also commonly referred to as bone bruise.

What is bone marrow edema?

Bone marrow edema is an area of changed density on the MR image that reflects either a traumatic bone bruise or a nontraumatic collection of the fluid within the bone.

NOTE: Bone bruise, bone contusion and bone marrow edema are often used as synonyms 6,8,9,10.


Types of Bone Bruise

  • A. Intraosseous bleeding 
  • B. Subperiosteal hematoma

A. INTRAOSSEOUS BLEEDING

Intraosseous bleeding [intra = within; os = bone] is what is most commonly referred to as bone bruise and what is the main part of this article.

Medical Definition

Bone bruise is a localized collection of blood within a bone associated with a fracture of the inner, spongy layer, but not the outer cortical layer of the bone, caused by an acute trauma 9,10.

Causes

Acute trauma due to:

  • The impact of the two bones in the joint or
  • Direct blow to the joint

Bone bruises are common in football, soccer, basketball and hockey players, in those who practice martial arts, in runners who run on hard surfaces; other common causes are falls and car accidents 1,6.

Symptoms and Signs

  • Swelling of the joint and, sometimes, one or more skin bruises, which do not result from a bone bruise but from injured ligaments, tendons, muscles and skin
  • Pain in the affected joint, which persists after the skin bruise ceases.
  • References 6,10

The Knee

bone bruise knee mri 2

Picture 1. An MRI of a bone bruise in the knee
See the white patch in the upper tibia
(source: physio-pedia.com, Creative Commons License)

  • Causes and mechanism. Sudden stop of running (deceleration), hard landing on a foot with slightly bent knee or direct side blow to the knee can result in the impact of the thighbone (femur) and shinbone (tibia) in the knee, what can cause a bone bruise in the lower part of the thighbone (lateral femoral condyle) and/or in the upper part of the shinbone (tibial plateau). Such an injury is often associated with a rupture of the anterior cruciate ligament (ACL), or medial (MCL) or collateral ligament in an athlete’s knee 1,4,6.
  • Pain and swelling arise from an injury of the soft tissues in the knee joint and not from a bone bruise 6.
  • Healing time. Most bone bruises associated with the anterior cruciate ligament rupture heal in 60 days, but the healing time may be as long as 2 years 10,30,41.
  • Recovery time. Most athletes who suffer from anterior cruciate ligament injury return to full sport activities within 6 months 6. The presence of a bone bruise does not seem to affect the recovery time 6.

Patella Dislocation and Bone Bruise

Side (lateral) dislocation of the patella can cause a bone bruise in the thighbone (in the lateral femoral condyle) and at the bottom of the patella 6.

The Ankle

A bone bruise in the ankle (in the lower part of tibia or/and in the talus bone) can occur after an ankle sprain (supination injury after landing on an outward rolled foot with the outer edge of the foot bearing weight) 1,4. Pain after an ankle sprain usually ceases after 4-6 weeks; the presence of the bone bruise usually does not add to pain and does not prolong the recovery time, which is about 3 months 28. In some individuals, a deep ankle pain during or after exercise may persist for some time. On an MR image, a bone bruise in the ankle can be sometimes seen even after 17 months, though 28.

bone bruise ankle talus mri

Picture 2. An MRI of a bone bruise in the ankle
A white area in the back of the talus bone
(source: physio-pedia.com, Creative Commons License)

Other Common Sites

  • Heel bone (calcaneus) after landing on the heels; partial weightbearing for about 4 months may be required 32  
  • The ball of the foot 33
  • Calf bone (fibula) in the part closer to the knee 18
  • Hip (the femoral head) 5
  • Pelvic bones: the ileal or pubic bone 34
  • Collarbone (clavicle) 36
  • Shoulder blade (scapula) 39
  • Shoulder: the head of the long bone (humerus) in the arm 38
  • Elbow 40
  • Wrist bones (hamate) 37
  • Spine (vertebra) 31

Types of Interosseous Bleeding Based on MRI

Type 1:  Reticular Bone Bruise

Reticular bone bruise is limited to the medullary bone, is distant from the cortical bone and not connected to the joint surface; it is usually mild and scarce 25.

 bone bruise ankle talus image mri  reticular bone bruise image

  Picture 3. Reticular bone bruise in the ankle
a) An MRI of a reticular bone bruise in the front of the talus bone (arrow)
b) Bone cracks in the medullary but not in cortical bone
dark grey = medullary bone; light grey = cortical bone
blue = cartilage; white = joint space
(source: PubMed Central, Creative Commons licence)

Type 2: Geographic Bone Bruise

Geographic bone bruise is bigger and more dense than a reticular bruise and situated closer to the cortical bone; it can bulge into the joint space (see Picture 4) 25.

geographic bone bruise image

Picture 4. Geographic bone bruise
Dark grey = medullary bone; light grey = cortical bone
blue = cartilage; white = joint space
(source: PubMedCentral, Creative Commons Licence)

geographic bone bruise knee mri image

Picture 5. An MRI of a large geographic bone bruise in the knee
(the large white area in the lateral femoral condyle)
(source: physio-pedia.com, Creative Commons license)

Type 2a: Osteochondral Fracture

When a geographic bone bruise communicates with a joint it is called osteochondral fracture 6. The damaged cartilage may need up to 1-2 years to heal 6.

Type 3: Impaction Bone Bruise

After an impact of the two bones in the joint, for example the tibia and femur in the knee, a depression of the articular surface and bone bruises on the both bones can form; this is called a  “kissing contusion” 4,9.

kissing contusion knee mri

Picture 6. An MRI of a kissing contusion in the knee.
The upper bone bruise is in the thighbone (femur) and the lower in the shinbone (tibia)
(source: orthopaedicsone.com, Creative Commons Licence)

Diagnosis

  • An X-ray can detect the real bone fracture but NOT an intraosseous bleeding (bone bruise within the bone) 25.
  • A CT also cannot detect intraosseous bleeding 25.

MRI

Currently, only Magnetic Resonance Imaging (MRI) can detect bruises within the medullary bone:

  • T1-weighted MRI shows a bone bruise as an area of decreased intensity 10.
  • T2-weighted fat suppressed MRI or MRI with Short T1 Inversion Recovery [STIR] sequences shows the area of increased intensity 10.

Bone bruise can  be detected by an MRI as soon as 1-30 hours after an injury 41.

Differential Diagnosis

Other conditions that can resemble a bone bruise:

  • Overuse or stress or insufficiency fracture due to repetitive microtrauma
  • Osteoarthritis
  • Osteochondritis dissecans
  • Subchondral cyst
  • Periarticular bone infarction
  • Bone tumor/cancer, lymphoma, multiple myeloma
  • Bone inflammation (polyarthritis, reactive arthritis) or infection (bacterial arthritis, osteomyelitis)
  • Osteopenia: scarce bone in malnourished individuals or those with anorexia nervosa
  • Paget’s disease
  • Gaucher’s disease
  • Algodystrophy
  • Intraosseous ganglion cyst
  • Idiopathic transient bone marrow lesion syndrome
  • Post-operative lesion
  • Red marrow hyperplasia
  • Intraosseous hematoma in individuals with bleeding disorders 26
  • References 6,10

Treatment

First Aid:

  • Elevate the affected limb
  • Put ice packs wrapped in the cloth over the affected joint for 5-10 minutes, few times a day for 1-2 days.
  • Reference 37

Treatment Options:

  • Rest, avoiding bearing weight on the affected limb; use of crutches or a cane as long as walking causes pain
  • Splint (brace)
  • Over-the-counter (OTC) painkillers and remedies to reduce pain and swelling
    • Nonsteroidal antirheumatic drugs (NSAIDs), such as ibuprofen
  • Physical therapy: nonbearing exercises to maintain full motion and prevent stiffness of the joint
  • Avoiding smoking — nicotine delays wound healing 2
  • Reference 6,10

There seems to be a lack of studies about the effectiveness of the following therapies on the bone bruise healing:

  • Microcurrent therapy
  • Kinesiology (kinesio) taping
  • Accupuncture
  • Vitamin A, C, K, and bromelain supplements

Healing and Recovering Time

Healing time is the time in which an evidence of a bone bruise disappears from an MR image. The healing time for most bone bruises in the knee is about 2 months bat can be as long as 2 years 10,30,41 and for the bone bruises in the ankle about 12 months or more 28. Reticular bone bruises heal fastest, followed by geographic and impaction bruises 6,10,30. Healing time is longer in older individuals and those with the knee osteoarthritis 30.

bone bruise knee tibia

Picture 7. MRIs showing the healing of a bone bruise in the knee
(A) A bone bruise in the tibia soon after the injury
(B) After 3 weeks
(C) Complete healing after 9 weeks
(source: physio-pedia.com, Creative Commons Licence)

Recovery time is the time in which an injured person can return to his or her usual activities. Recovery time can be shorter or longer than the bruise healing time and depends on the associated joint damage. The recovery time for most individuals with a bone bruise in the knee is shorter than 6 months and for those with a bruise in the ankle is about 3 months 19.

Complications

Possible complications of intraosseous bleeding:

  • Stiffness of the affected joint 10
  • Osteoarthritis, especially after a geographic bone bruise 4.
  • Avascular necrosis 10.

B. SUBPERIOSTEAL HEMATOMA

Subperiosteal hematoma is a collection of blood between the periost and the cortical bone 1,20.

Subperiosteal Hematoma in the Shinbone (Bruised Shin)

Subperiosteal edema in the shinbone usually results from a direct blow to the shins, commonly in those who practice martial arts and in football players. Symptoms include pain, bluish discoloration of the skin (from a skin bruise) and tender swelling, which usually start to diminish in 2-3 days, but can often persist for several months 47. Investigations are usually not needed; in doubtful cases diagnosis can be confirmed by an ultrasound, X-ray or CT 48. Bone bruise in the shinbone should not be confused with shin splints.

Treatment includes rest, elevation of the leg above the level of the heart, avoiding bearing weight on the leg, ice packs for 10-15 minutes several times a day for 1-2 days, and painkillers 24,47. Subperiosteal hematoma can get calcified and the new bone tissue can form 46,49.

The Eye Orbit

Subperiosteal hematoma in the orbit (usually in the orbital roof) can appear days, weeks or even years after direct blunt trauma to the eye; other causes include weightlifting, violent vomiting, labor, sinusitis, panic attack or scuba diving 20,21. It most commonly occur in young males 20. Spontaneous hematoma can appear in individuals with hemophilia, leukemia or scurvy 20. Symptoms include protrusion of the eye and blurred vision that worsens over the days. Spontaneous healing is possible 29. Treatment may include intravenous antibiotics, steroids, aspiration or surgery 20.

The Skull

Subperiosteal hematoma in various skull bones can appear in newborns and rarely in older individuals with various bleeding disorders. Symptoms may include skin bruises anywhere in the body and a bulge on the scalp. Hematoma can resolve spontaneously, and if not, it can be punctured. If not treated within one month it may lead to ossification, which requires surgical removal 23.

Other Sites for Subperiosteal Hematoma

Pelvic bone (iliac or pubic bone): after a blunt or penetrating trauma 22.

Tailbone (coccyx): pain can last for several weeks or, rarely, it can become chronic — in this case surgery can be considered. Sitting on doughnut cushions can help to prevent pain 43

coccyx (tailbone) bruise picture

Picture 8. Tailbone bruise (coccyx hematoma)
(source: wikidot.com, Creative Commons licence)

  • Collarbone (clavicle) 35
  • Ribs or breastbone (sternum); may be hard to distinguish from a rib fracture; hematoma can be detected by an ultrasound; pain may last for 2-4 weeks 44,45.
  • Forearm 37

What is a deep bone bruise?

The term deep bone bruise may be used for a bruise within the medullary bone (intraosseous bleeding) as opposed to a subperiosteal hematoma, which is a superficial bone bruise.

Bone Bruise vs Real, Stress and Occult Fracture

  • In a real bone fracture, both the cortical bone (the outer layer) and the medullary bone (the inner layer) are completely broken with the bone parts separated, what can be seen on an X-ray.
  • In a stress fracture due to repeated trauma, both the cortical and medullary bone are broken, but the bone parts on the both sides of the fracture do not split. Stress fracture can be sometimes detected by an X-ray, and if not, an MRI can be used 15.
  • In an occult bone fracture both the cortical and medullary bone are broken, but the fracture line is so thin that it is not detected by an X-ray 3. The occult bone fracture that involves the bone and the cartilage and makes a communication between a bone bruise and the joint is called osteochondral fracture 6.
  • In a bone bruise, only the medullary bone is broken and the cortical bone remains intact. A bone bruise cannot be detected by an X-ray or CT but only by an MRI 3.

NONTRAUMATIC BONE MARROW EDEMA

Bone marrow edema is a term used to describe nonspecific changes of the density on the MRI image of the bone, which can include bone bruise (blood collection), true edema (fluid collection), or localized inflammation. Nontraumatic bone marrow edema can be associated with various bone disorders:

The Wrist and Hand

  • In rheumatoid arthritis, a bone marrow edema in the wrist is an early sign; it appears before rheumatoid factor 16 and is a bad prognostic sign 10,17.

The Foot

  • Bone marrow edema-like syndrome (BMES) of the foot and ankle:
    • Younger patients with pain in the foot or ankle, without a known cause
    • Conservative treatment with splints may help.

The Hip

  • Avascular necrosis of the femoral neck 10
  • Transient osteoporosis of the hip (TOH) in women in the 3rd trimester of pregnancy or in middle-aged men 10,11
    • Main symptom: severe, disabling pain in the lateral thigh, no tenderness
    • Can be treated solely with analgesics
    • Heals completely after delivery

The Spine

  • In spondyloarthritis, a bone marrow edema can be the first finding on an MRI 10.

Reactive Bone Marrow Edema

Reactive bone marrow edema refers to changes in the MR image caused by a response of the bone tissue to inflammation, and may be caused by:

  • Benign and malign bone tumors
  • Osteoporosis
  • Osteitis
  • Osteoarthritis (edema is a bad prognostic sign)
  • Osteonecrosis
  • Transient bone marrow edema syndrome
  • Ganglion cyst
  • Complex regional pain syndrome
  • Reference 14

ICD 9 and 10 Code

The ICD 9 code for bone bruise in general (including interosseous bleeding and subperiosteal hematoma) is the same as for “contusion, unspecified,” which is 924.9, and the ICD 10 code is T14.9027.

ICD codes by location of contusion:

  • Contusion of hip: ICD 9 = 924.01; ICD 10 = S70.00XA 42
  • Contusion of knee: ICD 9 = 924.11; ICD 10 = S80.00XA 42
  • Contusion of ankle: ICD 9 = 924.21; ICD 10 = S90.00XA 27
  • Contusion of finger: ICD 9 code = 923.3; ICD 10 code = S60.00XA: ICD 10 code for contusion of thumb without nail damage = S60.019.A 50

20 Responses to Bone Bruise or Contusion

  1. Michael Trowbridge says:

    Hell0, How do I find your references? In particular, what is reference #6?
    Regards

  2. Kristi Hardgrove says:

    Do you have any additional info on #37. I had an MRI and was told I have a bone bruise. I am in a lot of pain and they want to immobilize it for four to six weeks 24/7 …. at least as much as possible with a brace.
    It has been a year with this pain and it seems a long time for what they term a “bruise”. Any additional information would be appreciated.

    • Jan Modric says:

      Kristi, what additional info (#37 ?)? A bone bruise can actually last as long as you mentioned. I which exact bone do you have a bruise and how it happened?

  3. Kaityn says:

    What would the reason be to send someone to get blood work done after an MRI showed a bone bruise on the knee? Was informed they were worried about the large size of the bruise and there was a patchy area. There was no further elaboration on the reason for the blood test.

    • Jan Modric says:

      Kaityn, they could check for an eventual blood clotting disorder, which could be the reason for the large bruise size. Another reason is to rule out bone cancer or some other disorder.

  4. Donna says:

    After a bad fall I had an MRI. No fracture on xrsys) Rheumatologist using ultrasound diagnosed wrist haemarthrosis. He said MRI showed evidence of bone bruising. After 6 wks I expected more healing. Large lump still on back of my hand, expected further 6 wks to heal. Tendons in my wrist ‘snap’ painfully. wrist still aching. Will there be lasting damage?

    • Jan Modric says:

      Donna, bone bruise may need several months to heal. The lump you’ve describe is not from bone bruise but from the swelling of the joints in the wrist. You may want to ask a doctor if a steroid injection would help. It is possible that your wrist will heal completely, but you probably need to give it more time.

  5. Columbusgal says:

    My 76 year-old mother was diagnosed with a “very large and bad bone bruise” of the left knee, along with an ACL tear and tears in her meniscus. She had a scope but continued to have significant pain and swelling. Four weeks after her scope (right and left side of her meniscus were removed) we took her back in due to ongoing pain and swelling. The MRI showed avascular necrosis with collapse of her bone on the outside of her left knee. She will have a total knee replacement tomorrow. Could the avascular necrosis be a direct result of her bone bruising? After the knee replacement, is there any possibility the bone could continue to die? Thank-you for taking the time to answer my questions.

    • Jan Modric says:

      Columbusgal, it is possible that avascular necrosis is a direct result of bone bruise, but they both have developed as a result of an injury if I imagine this right. Avascular necrosis can also develop after an injury without a bone bruise. If the damaged bone will be removed and replaced, I see no reason why would her knee bone continue to die — assuming that surgery will go well and her bones are otherwise healthy.

  6. Joe says:

    Going on almost a year of severe pain after a slip and fall. The MRI shows edema of the bone marrow of the 4th metatarsal. I have had steroid injections, iced, immobilized, cold laser therapy but nothing seems to work. I have been to many doctors but none have been able to give any sort of care plan. Has anyone found something has worked? Getting desperate for something to work.

    • Jan Modric says:

      Joe, this is quite specific question. You may want to join some of health forums to get more ideas.

  7. Mary Helen Moore says:

    I fell on 6/9/16 and injured my R hip and suffered a small labrum tear along with the MRI noting a bruise in the hip area. I also suffered a tibia plateau fx just below the kneecap on my L leg. I am in my late sixties and have an appt to see an Ortho. I was out of State at the time and saw my family MD on 6/24. Can you suggest specific questions I should ask the Ortho about the hip bruise? At the time the ER MD told me to keep active not knowing I had fx’d my L leg so I had been walking on both injuries since 6/9!!!!

    • Jan Modric says:

      Mary Helen, by keeping active the doctor probably meant not to rest in bed, but maybe not walking around too much.

      You may want to ask the orthopedist:
      – What is the exact name of the damage in the femoral head and hip joint (“bone bruise,” “hair fracture” “bone marrow edema” “labrum tear,” etc.)? Write down the answer or ask for a copy of a document with the exact diagnosis.
      – In what time you can expect full recovery? Do not be surprised if it will be “one year.”
      – How active should you be: to walk or not, to have some exercises or not…?
      – Medications to take or avoid?

      Note that when the pain goes awaythis does not already mean that the bone bruise has healed completely (this can be evaluated by another MRI, if necessary).

  8. Val says:

    I hit my ankle one week ago, there was an immediate large haematoma due probably to chlopydegrol and aspirin intake. It is now 10 days later still in a lot of pain and whole foot is swollen. Icing up to 5 times a day the foot cannot bear to be warm

  9. Renee says:

    Just diagnosed with talus bone marrow edema from recent MRI and instructed on complete non weight bearing of the foot. Initial injury was 4 months ago with hyperextension inversion injury, wore a boot for 5 weeks after injury. How dangerous is this injury and would it be ok to do a 70 mile bike ride in 2 months.

    • Jan Modric says:

      Renee, bone marrow edema heals slowly, so I personally would avoid any extra physical activity for some time (probably 1 year from initial injury). But the doctor should know better.

  10. Susan Anderson says:

    I sprained my left ankle in mid May, within 24 hours foot started turning purple and swelling, quite similar to CRPS, which I experienced in my right arm in 2008. Foot turned green, yellow and all bruising disappeared in about a month. X-rays of foot and ankle negative. I continued to have symptoms of CRPS (on/off swelling, extreme pain, tingling, muscle twitching, extreme cold etc). Finally had MRI mId August, diagnosed 3 bone contusions. Could I have both bone bruise and CRPS? I used crutches for about 6 weeks, foot still hurts quite a bit and most of CRPS symptoms remain. Thank you…

    • Jan Modric says:

      Susan, bone bruise causes pain and is obviously associated by skin bruising. Bone bruise by itself should not cause temperature changes, muscle twitching and tingling, so you may want visit a neurologist.

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