Dark red to purple to black skin discoloration is the presentation. Many factors modify the clinical presentation of contusions. These include the type of tissue affected, severity of trauma, age, sex, skin color and systemic diseases (like bleeding disorders). Systemic diseases usually give rise to small bruises (petechiae) whereas trauma or mechanical compression causes single large contusions involving vast expanse of skin.

Clinical presentation of contusion also depends on the affected organ. Based on the involved structure, contusions are of following types.

• Subcutaneous contusion (underneath the skin)
• Muscular contusion (involving muscle tissue)
• Periosteal ontusion (involving bone)
• Pulmonary contusion (involving lung) [2] [3]
• Cerebral contusion [4] [5]
• Myocardial contusion [6] [7] [8]

Subcutaneous contusions present as:

• Purple or bluish discoloration of the skin
• Localized pain
• Swelling

Intramuscular contusions seldom show on the skin surface. Pain is the main symptom of such contusions. Limitation of the range of motion is also common in such cases. Periosteal contusions are the most painful ones and may present as visible swelling. Pulmonary contusion is accompanied by respiratory symptoms like difficulty in breathing or wheezing. Cerebral contusions present with headache, impaired orientation, vomiting, seizures, syncope and coma.

Workup in contusions consists of the following elements.

• Physical examination for muscle contusions
• X-ray for pulmonary contusions
• CT scans for cerebral contusions
• MRI for cerebral contusions
• Ultrasound for intraabdominal contusions
• Complete blood count (CBC) for assessment of bleeding disorders
• Serum creatinine kinase levels

The treatment of contusions consists of:

• Rest
• Cold packing
• Compression
• Limb immobilization
• Elevation to prevent the pooling of blood and subsequent edema formation.
• Analgesics, for example, acetaminophen to relieve mild pain. It can be combined with codeine, oxycodone or hydrocodone for moderate to severe pain.
• Anti-inflammatory drugs, like non-steroidal anti-inflammatory drugs (NSAIDS) to reduce swelling.
• Corticosteroid therapy should be avoided as it interferes with the healing process.
• Physiotherapy may be required as a rehabilitative measure for muscle contusions.
• Treatment of the underlying cause.
• Surgical treatment is sometimes required in special cases such as cerebral contusion and compartment syndrome [9][10].

Massive internal contusion can prove to be fatal if left untreated [1]. Other causes like leukemia, thrombocytopenic purpura, hemophilia, subdural hematoma etc. can also lead to fatal complications if not addressed properly.

There are many different causes of contusion. Most commonly, it occurs due to blunt trauma (as a result of fall, blunt ended weapon injury, sports injury etc.). Mechanical compression of the tissues as seen in road traffic accidents may also cause contusions. Fractures and ligament tears (such as anterior or posterior cruciate ligaments tears) are also associated with the development of bruising and contusion. Muscle strains may also lead to the formation of contusions. Bites received from animals may also cause the formation of contusions.

Internal organs may also develop contusions as a result of trauma. Intraabdominal contusions are very frequent after blunt abdominal injuries. Injuries to the head may cause the development of intracerebral hemorrhage, subdural hematoma and subarachnoid hemorrhage.

A number of diseases and conditions predispose the patient to the development of contusions. Notable among them are bleeding disorders such as hemophilia B (Christmas disease). Deficiency of the factors involved in the clotting cascade (such as deficiency of factors II, V, VII and X) also increase the risk for the formation of contusions. Contusions are also frequently seen in the patients with reduced platelet count and those with von willebrand disease. Henoch Schloein purpura is also associated with deep bruising. Leukemias may also predispose the patient to the development of contusions.

The exact prevalence of contusions is difficult to establish as majority of the cases go unreported. Contusions are more common in young children and teenagers. Individuals with bleeding and coagulation disorders are also at higher risk.

One-third of the sports injuries result in muscle contusions. Rotator cuff and gastrocnemius injuries are the commonly reported ones.

When external trauma occurs to the tissues, the localized blood vessels rupture. The blood oozes out and accumulates in the tissue spaces, causing formation of a hematoma. Injury to the capillary endothelium triggers the release of endothelin that causes the vasoconstriction, preventing further leakage of blood out of the vessels.

The injury also causes the release of Von-Willebrand factor that triggers the coagulation cascade, resulting in localized clot formation to stem the blood leakage. Involvement of nerve endings can give rise to pain sensations.

The blood is clotted and plugged locally. Tissue plasminogen activator begins the clot resolution, during which the hematoma or the bruise undergoes various color changes due to accumulation of hemoglobin breakdown products as a result of phagocytosis of cellular debris. The clot ultimately dissolves completely.

The age of the bruise can be estimated by external skin discoloration.

• Red: 0-2 days
• Blue or purple: 2-5 days
• Green: 5-7 days
• Yellow: 7-10 days
• Brown: 10-14 days

• Safety equipment like helmets and driving belts should be employed while driving or riding a bike.
• Proper head gear should be worn while engaging in close contact sports like wrestling and boxing in which the risk of blows and blunt trauma is high.
• In case of diagnosed bleeding disorders, care should be exercised to avoid bruising as a result of fall or similar trauma.
• Easy bruising is indicative of a more sinister pathology and must be immediately brought to the attention of a consultant.
  Immediate management of injuries should be done to avoid fatal complications like pulmonary contusion.

Commonly referred to as a deep bruise, a contusion develops as a result of rupture of small blood vessels and the accumulation of blood in the tissue spaces. Purple or bluish discoloration is the common presentation of a contusion. The underlying pathology and the clinical presentation of contusions vary greatly. Conservative treatment modalities can help in healing of contusions.

A contusion or bruise is accumulation of blood as a result of bursting of small blood vessels as a result of blunt force trauma or a multitude of other causes. Bleeding disorders like hemophilia can also precipitate bruising. Result is deep purple or bluish discolorations, swelling and pain. A bruise usually resolves itself in about 2-3 weeks.

Observing road safety measures can prevent contusions due to major trauma like accidents. Other preventive measures include wearing head gear and protective padding during sports activities. If bruising occurs repeatedly and even after minor injuries, a physician should be immediately consulted as it may indicate presence of other threatening conditions.

1. Vougiouklakis T, Peschos D, Doulis A, Batistatou A, Mitselou A, Agnantis NJ. Sudden death from contusion of the right atrium after blunt chest trauma: case report and review of the literature. Injury. Jan 2005;36(1):213-217.
2. Cohn SM. Pulmonary contusion: review of the clinical entity. The Journal of trauma. May 1997;42(5):973-979.
3. Allen GS, Coates NE. Pulmonary contusion: a collective review. The American surgeon. Nov 1996;62(11):895-900.
4. Stuck RM. Cerebral contusion of the newborn. Rocky Mountain medical journal. Jan 1952;49(1):44-47.
5. Vallenas Orihuela M. [Physiopathology of cerebral contusion]. Revista de neuro-psiquiatria. Sep 1971;34(3):197-209.
6. Tenzer ML. The spectrum of myocardial contusion: a review. The Journal of trauma. Jul 1985;25(7):620-627.
7. St Louis P, Gandhi S. Cardiac contusion and creatine kinase-MB: a pertinent case history and brief review of the utility of CK-MB. Clinical biochemistry. Apr 1994;27(2):105-111.
8. Menzies RC. Cardiac contusion: a review. Medicine, science, and the law. Jan 1978;18(1):3-12.
9. Kawamata T, Katayama Y. Surgical management of early massive edema caused by cerebral contusion in head trauma patients. Acta neurochirurgica. Supplement. 2006;96:3-6.
10. Gorman PW, McAndrew MP. Acute anterior compartmental syndrome of the thigh following contusion. A case report and review of the literature. Journal of orthopaedic trauma. 1987;1(1):68-70.