Hematoma vs DVT

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recently had patient who was on coumadin present with hematoma dorsum metatarsal cuneiform area . Can this have potential for DVT.

 

Bunion


People on warfarin often bruise and leak blood from minor vessels. Their physician can adjust dosage to optimise the therapy and minimise the side effects.


Cheers Dave

 

Hi Bunion,

A bruise is caused by bleeding from vessels into the surrounding tissue. You and I don't bruise as easily as patients on Warfarin because unlike they, we have an abundance of vit K dependent clotting factors (ii, vii, ix, x) that allow prompt cessation of bleeding from damaged vessels via normal heamostasis.

A DVT is caused by the formation of a thrombus within the vessel itself. A thrombus is never normal, it is always pathological and different to the fibrin plugs that are formed in normal haemostasis.

Given that a bruise is an extravascular process, it can not cause a DVT which is always due to intravascular thrombosis. Indeed your patient's treatment with warfarin (provided they have a therapeutic INR), is protective against the formation of DVT.

Just as a side note, as part of the normal aging process our vessels do become more fragile and more susceptible to bleeding from minor trauma. Most of the warfarinised patients that we see are elderly, providing a double whammy so to speak, resulting in the frequent, sometimes quite large bruising from which many of them suffer.

I hope that helps to allay your fears Bunion.

Lauren
(Long time member, first time poster.)

 

Thanks for your comments appreciated . The rest of the story- The patient is 70 year old Niddm with on anticoagulant who presented to my office one week after noticing a bruise on the top of her foot while on vacation in another state. She went to an emergency room and was placed on an antibiotic . She does not recall xrays being taking nor doppler at the time. She thinks she twisted her foot.
Patient presents in slip on canvas sneaker w/o crutches nor compression. There is swelling ecchymosis
dorsum of her foot ,integument intact with no cellulitis . Denies fever chills afebrile. Patient is able to ambulate with minimal discomfort. Discomfort is during non weight bearing when her foot points down,also with direct pressure to dorsum 2nd 3rd metcuneiform area and active dorsiflexion with resistance to forefoot. Diagnosis at time -hematoma ,lis franc's sprain,possible charcot.
Foot xrays reveal a gap lis francs area 2nd and 3rd metcuneiform with no evidence of fracture or periosteal activity,or demineralization. Treament compression splint applied ,rest, discussed possible aspiration if no improvement , cam walker pending clinical response.
Patient rtc 1 week ambulating with decrease complaints. Swelling decreased ,decreased ecchymosis, decreased size of hematoma temp integument wnl. Patient also states she has resumed home exercises for weight reduction including bicycling and single limb stance without pain.
Diagnosis resolving hematoma, lisfarancs sprain. no aspiration due to improvement and clinical response. Treatment rx elastic compression ankle stocking.Avoid foot exercises at this time. Rtc 2 weeks,
The following day the patient had her yearly visit with her pcp who stated that she had an emergency situation , that she had a life threatening blood clot ,referred her to a surgeon within same conglomerate hospital ,and operated on the lesion. I was never consulted . Personally I feel it was unnecessary to expose the patient to the risk- she was responding to conservative treatment. Mri.DX ultrasound were not performed due to clinical improvement.
Difference of opinion? Looking forward to comments thanks.