Review
Traumatic bone bruising—A review article

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Abstract

The radiological assessment and classification of bone bruising are reviewed. Most of the literature relates to the knee and the effect of various injuries and their pattern of bone bruising is reviewed. The natural history of bone bruising and biochemical changes are also considered.

Introduction

Trabecular bone appears susceptible to injury from trauma without disruption of the overlying cortical bone. Recently MRI has proved to be a powerful tool to assess these radiographically occult injuries and has been the investigation of choice to assess acute bony injuries especially when clinical examination is equivocal. With the increasing application of MRI to patients with acute musculoskeletal trauma, more occult traumatic lesions of bone are being identified.

Although bone bruising is described in relation to many bones and joints such as the elbow, ankle, calcaneum and vertebrae, most of the evidence regarding bone bruising in the literature refers to the knee joint.

Section snippets

Radiological assessment of bone bruise

The terms bone bruise or bone contusion have been used synonymously and are thought to represent a spectrum of occult bone injuries, including bleeding, infarction and oedema due to microscopic compression fractures of cancellous bone [1], [2], [3]. Bone bruising on MRI scan is best diagnosed by the increased signal intensity seen on T2 images with decreased signal intensity seen on T1. T2 weighted images reflect the presence of free water (oedema, haemorrhage or inflammatory response) and

Classification of bone bruising

Yao and Lee were the first to describe a series of eight patients with acute knee injury and with normal radiographs but in whom MRI showed irregular foci of increased signal on T2 weighted and low signal on T1 weighted spin-echo (SE) images [6]. The same year, Berger et al. described radiologically occult fractures on MRI in a series of 14 patients but these lesions were not classified [7]. Mink and Deutsch identified the following four types of fractures occurring about the knee: bone

Bone bruise: a footprint of the mechanism of injury

The bone contusion pattern is described as a footprint of the mechanism of injury and it is suggested that by studying the distribution of bone contusion one can understand the mechanism of injury and thereby predict the associated soft tissue abnormality that may be present [12]. The precise location of the bone bruise thus allows for a focused search for predictable patterns of associated internal derangements.

Pivot shift injury in the knee results in disruption of the anterior cruciate

Medial collateral ligament

Miller et al. studied isolated MCL injury and bone bruising [14]. They found bone bruising in only 45% of patients with MCL injuries, approximately one half as many as bone bruises associated with ACL injuries. This lower prevalence of bone bruising with MCL injury compared to ACL injury is possibly due to the greater force required for ACL injury. Complete resolution of such bruising occurred over a 2–4 months period. Most of the lesions in association with MCL injury were located in the

Natural history of bone bruising

Follow up MRI scans of 30 patients who had acute knee injury with bone bruising showed persistent but reduced bone bruising on follow up MRI scan at 12–14 weeks [31]. Eighty percent of the patients had greater than 50% reduction in bone bruise volume while 17% had less than 50% reduction in bone bruise volume. They demonstrated two types of bone resolution; one from the periphery (centripetal) and one towards the joint margin. Patients who had resolution towards the joint margin were found to

Bone bruising and its osteochondral sequelae

Even though there might not be any obvious injury to the articular cartilage, blunt injury to the cartilage may have significant effects on future cartilage metabolism [41], [42], [43], [44].

In the experimental study by Radin et al., the knee joints of adult rabbits were subjected to repetitive impact loading at physiological levels [45]. This resulted in changes in their knee joints consistent with those of degenerative joint disease. The cartilage destruction was preceded by abnormality of

Bone bruising and biochemical change

Blunt injury to the articular cartilage and subchondral bone, along with concomitant injury to the menisci and ligament rupture, activates the chemical inflammatory response within the knee [57], [58].

Chemical mediators or cytokines (tumor necrosis factor-alpha) that are released after injury to the ACL, chondrocytes, extracellular matrix, menisci or subchondral bone are potentially responsible for the increased size and duration of effusion, increased pain, and longer time to achieve normal

Conclusion

Although the natural history of bone bruising is not entirely known, recent studies in the literature have suggested possible outcomes of bone bruising. The majority of these studies are retrospective and more prospective long-term studies are required to closely look at the natural history of bone bruising and its clinical consequences.

Many studies have shown that bone bruising may have a deleterious effect on the overlying articular cartilage. However there are a few studies stating

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