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 a subperiosteal hematoma?
A 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.
A 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.
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
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 sports 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.
A bone bruise in the ankle (in the lower part of the 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 the 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 sometimes be seen even after 17 months, though 28.
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 weight-bearing 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
A 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.
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 license)
Type 2: Geographic Bone Bruise
A geographic bone bruise is bigger and denser than a reticular bruise and situated closer to the cortical bone; it can bulge into the joint space (see Picture 4) 25.
Picture 4. Geographic bone bruise
Dark grey = medullary bone; light grey = cortical bone
blue = cartilage; white = joint space
(source: PubMedCentral, Creative Commons license)
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.
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 license)
- 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.
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.
A bone bruise can be detected by an MRI as soon as 1-30 hours after an injury 41.
Other conditions that can resemble a bone bruise:
- Overuse or stress or insufficiency fracture due to repetitive microtrauma
- 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
- 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
- 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
- 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
- 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.
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 license)
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.
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
A subperiosteal hematoma is a collection of blood between the periosteum and the cortical bone 1,20.
Subperiosteal Hematoma in the Shinbone (Bruised Shin)
A 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 ultrasound, X-ray or CT 48. A 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. A subperiosteal hematoma can get calcified and the new bone tissue can form 46,49.
The Eye Orbit
A subperiosteal hematoma in the orbit (usually in the orbital roof) can appear days, weeks or even years after blunt trauma to the eye; other causes include weightlifting, violent vomiting, labor, sinusitis, panic attack or scuba diving 20,21. It most commonly occurs in young males 20. A 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.
A 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. A 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
Picture 8. Tailbone bruise (coccyx hematoma)
(source: wikidot.com, Creative Commons license)
- Collarbone (clavicle) 35
- Ribs or breastbone (sternum); may be hard to distinguish from a rib fracture; hematoma can be detected by 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. A stress fracture can sometimes be 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.
- 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.
- 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
- 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
- Osteoarthritis (edema is a bad prognostic sign)
- Transient bone marrow edema syndrome
- Ganglion cyst
- Complex regional pain syndrome
- Reference 14
ICD 9 and 10 Code
The ICD 9 code for a bone bruise in general (including interosseous bleeding and a 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
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