Definition
Bruises, or ecchymoses, are a discoloration and tenderness of the skin or mucous membranes due to the leakage of blood from an injured blood vessel into the tissues. Purpura refers to bruising as the result of a disease condition. A very small bruise is called a petechia. These often appear as many tiny red dots clustered together and could indicate a serious problem.
Description
Bruises change colors over time in a predictable pattern, so that it is possible to estimate when an injury occurred by the color of the bruise. Initially, a bruise will be reddish, the color of the blood under the skin. After one to two days, the red blood cells begin to break down, and the bruise will darken to a blue or purplish color. This color fades to green at about day six. Around the eighth or ninth day, the skin over the bruised area will have a brown or yellowish appearance, and it will gradually fade back to its normal color.
Long periods of standing cause blood that collects in a bruise to seep through the tissues. Bruises are actually made of little pools of blood, so the blood in one place may flow toward the ground, and the bruise may appear in another location. For instance, bruising in the back of the abdomen may eventually appear in the groin; bruising in the thigh or the knee will work its way down to the ankle.
Demographics
All persons develop bruises at many times during their lives. The condition is entirely natural and normal.
Causes and Symptoms
Healthy people may develop bruises from any injury that does not break through the skin. Vigorous exercise may also cause bruises due to bringing about small tears in blood vessels walls. In a condition known as purpura simplex, there is a tendency to bruise easily due to an increased fragility of the blood vessels. Bruises also develop easily in the elderly, because the skin and blood vessels have a tendency to become thinner and more fragile with aging, and there tends to be an increased use of medications that interfere with the blood clotting system. In the condition known as purpura senilis, the elderly develop bruises from minimal contact that may take up to several months to completely heal.
The use of nonsteroidal anti-inflammatories such as ibuprofen and naproxen sodium may lead to increased bruising. Aspirin, antidepressants, asthma medications, and cortisone medications also have this effect. The anticlotting medications also known as blood thinners, especially the drug warfarin (Coumadin), may be the cause of particularly severe bruising.
Sometimes bruises are linked with more serious illnesses. There are a number of diseases that cause excessive bleeding or bleeding from injuries too slight to have consequences in healthy people. An abnormal tendency to bleed may be due to hereditary bleeding disorders, certain prescription medications, diseases of the blood such as leukemia, and diseases that increase the fragility of blood vessels. If there are large areas of bruising or bruises develop very easily, this may herald a problem. Other causes that should be ruled out include liver disease, alcoholism, drug addiction, and acquired immune deficiency syndrome (AIDS). Bruising that occurs around the navel may indicate dangerous internal bleeding; bruising behind the ear, called Battle's sign, may be due to a skull fracture; and raised bruises may point to autoimmune disease.
When to Call the Doctor
A physician or healthcare professional should be consulted when accidents involve extensive bruising or when bruises do not heal in a timely manner (seven to 10 days). A physician should be called if bruises appear in unusual locations on the body such as on the back or around the eyes or wrists. Such injuries are often the result of abuse.
Diagnosis
Bruising is usually a minor problem that does not require a formal medical diagnosis. However, faced with extensive bruising, bruising with no apparent cause, or bruising in certain locations, a physician will pursue an evaluation that includes a number of blood tests. If the area of the bruise becomes hard, an x ray may be required.
Treatment
A bruise by itself usually requires no medical treatment. It is often recommended that ice packs be applied on and off during the first 24 hours after injury to reduce the bruising. After that, heat, especially moist heat, is recommended to increase the circulation and the healing of the injured tissues. Rest, elevation of the affected part, and compression with a bandage will also retard the accumulation of blood. Rarely, if a bruise is so large that the body cannot completely absorb it or if the site becomes infected, it may have to be surgically removed.
Several types of alternative treatments are often recommended to speed healing and to reduce the pain associated with bruises. Most of these treatments are topical in nature and frequently include vitamin K cream can be applied directly to the site of injury. Astringent herbs such as witch hazel, Hamamelis virginiana, can be used. This treatment will tighten the tissues and therefore diminish the bruising. The homeopathic remedy, Arnica montana, can be applied as a cream or gel to unbroken skin.
Oral homeopathic remedies may reduce bruising, pain, and swelling as well. Arnica montana, at 30 ml (1 oz), taken one to two times per day is highly recommended.
Prognosis
The blood under the skin which causes the discoloration of bruising should be totally reabsorbed by the body in three weeks or less. At that time, the skin color should have completely returned to normal.
Sometimes a bruise may become solid and increase in size instead of dissolving. This may indicate blood trapped in the tissues, which may need to be drained. This condition is referred to as a hematoma. Less commonly, the body may develop calcium deposits at the injury site in a process called heterotopic ossification.
Prevention
Vitamin K promotes normal clotting in the blood and, therefore, may help reduce the tendency to bruise easily. Green leafy vegetables, alfalfa, broccoli, seaweed, and fish liver oils are good dietary sources of vitamin K. Other good foods to eat are those containing bioflavonoids, such as reddish-blue berries. These can assist in strengthening the connective tissue, which decreases the spread of blood and bruising. Zinc and vitamin C supplements are also recommended for this purpose.
Nutritional Concerns
A balanced diet that includes green leafy vegetables and broccoli should provide a sufficient source of vitamin K. Vitamin C and zinc supplements are also helpful.
Parental Concerns
Parents should provide a balanced diet for their children. They should also provide appropriate care for bruises that inevitably occur.
Resources
Books
Gordon, Sharon, and Nanci Varquis. Bruises. New York: Scholastic Library Publishing, 2002.
Royston, Angela. Bumps and Bruises. Orlando, FL: Heinemann Library, 2004.
——. Why Do Bruises Change Color?: And Other Questions about Blood. Orlando, FL: Heinemann Library, 2003.
Periodicals
Baruch, M. B., and R. Beck-Little R. "A 12-year-old boy with multiple bruises and a dislocated knee but no reported injury." Journal of Emergency Nursing 30, no. 3 (2004): 213–5.
Gates, D. "Burgers or bruises? Being assaulted shouldn't be part of a nurse's aide's job." American Journal of Nursing 104, no. 9 (2004): 13–4.
Sibert, J., et al. "Bruising, coagulation disorder, and physical child abuse." Blood Coagulation and Fibrinolysis 15, no. Supplement 1 (2004): S33–9.
Yamagami, T., et al. "Clinical features of snowboarding injuries." Journal of Orthopedic Science 9, no. 3 (2004): 225–9.
Organizations
American Academy of Emergency Medicine. 611 East Wells Street, Milwaukee, WI 53202. Web site: www.aaem.org/.
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: www.aafp.org/.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: www.aap.org/.
American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611–3604. Web site: www.aapmr.org/.
American College of Emergency Physicians. PO Box 619911, Dallas, TX 75261–9911. Web site: www.acep.org/.
American College of Osteopathic Emergency Physicians. 142 E. Ontario Street, Suite 550, Chicago, IL 60611. Web site: www.acoep.org/.
American College of Sports Medicine. 401 W. Michigan St., Indianapolis, IN 46202–3233. Web site: www.acsm.org/.
Web Sites
"Bruises." MedlinePlus. Available online at www.nlm.nih.gov/medlineplus/bruises.html (accessed December 7, 2004).
"Bruises/Contusions." ForensicMD. Available online at www.forensicmed.co.uk/bruises.htm (accessed December 7, 2004).
"Bruises, Ouch!" University of Iowa Health Science Relations. Available online at www.vh.org/adult/patient/familymedicine/prose/bruises.html (accessed December 7, 2004).
[Article by: L. Fleming Fallon, Jr., MD, DrPH]
