yogabook / pathologie / bone bruise (bone contusion)

bone bruise / bone contusion / bone marrow edema/ Knochenkontusion

Definition of

Bone bruising is a frequently overlooked injury due to its non-specific symptoms, especially as it is often accompanied by soft tissue bruising. Bone bruises (the „bruise of the bone“) are microfractures of the cancellous bone with bleeding into the fatty marrow, surrounding oedema and focal new bone formation; they were first described in 1988. Bone bruises often occur as concomitant damage to a ligament injury in the knee or ankle joint. Bone bruises can be divided into 5 grades, the most severe of which is the stress fracture. Bone marrow edema itself does not necessarily require treatment. Bone marrow edema is common in professional runners (87.5% in one study ) and is usually asymptomatic. Bone marrow edema can therefore only be evaluated together with the clinical symptoms: only pain makes bone marrow edema worthy of clarification and possibly treatment. Long-term bone marrow edema can disrupt blood circulation and lead to necrosis. While bone marrow edema often occurs close to the joint, classic stress fractures tend to occur in bones of the lower extremities that are subject to heavy loads: Tibia, fibula, scaphoid, metatarsals, femur, patella, pelvis or calcaneus, in rowers also preferentially on the ribs. The classification into degrees:

1. 0: normal periosteum, normal bone marrow, no stress reaction
2. 1: Mild periosteal edema (MRI T2), normal bone marrow, stress reaction
3. 2: Severe periosteal edema (MRI T2), bone marrow edema (MRI T2), stress reaction
4. 3: Severe periosteal edema (MRI T1 and T2), severe bone marrow edema (MRI T1 and T2), stress fracture
5. 4: Fracture line in the periosteum (MRI T1 and T2), bone marrow fracture line (MRI T1 and T2), stress fracture

Cause

1. Single trauma or chronic repetitive trauma: with or without external factors, i.e. both impact trauma and supination trauma
2. Atraumatic forms with corresponding risks or stresses
3. Inflammations
4. arterial deficiency (ischemic cause)
5. Drainage disorders (venous, lymphatic)
6. Fractures
7. metabolic causes: Diabetes mellitus, metabolic diseases
8. degenerative causes
9. Secondary for malignant events

Predisposing

1. Static errors, axis deviations
2. Overuse
3. Material defects in sport
4. Overweight

Diagnosis

1. MRI; a bone bruise only becomes visible on X-ray at an advanced stage
2. X-ray: only informative in the case of pronounced stress fractures

Symptoms

1. Initially: pain on exertion
2. Knocking pain
3. later: rest pain, night pain
4. Later: Restriction of flexibility and activity, especially sports
5. later: pain peaks during exercise
6. local edema

Complications

1. Bone necrosis with risk of fracture
2. Lymphoedema
3. venous edema, varices
4. Disturbance of joint function, untreated: osteoarthritis osteochondrosis dissecans

Therapy

The degree of protection depends on the degree:

1. 0: none
2. 1: 2-3 weeks training break
3. 2: 4-6 weeks training break
4. 3: 6-9 weeks training break
5. 4: 6 weeks in plaster, then 6 more weeks off training

As bone marrow edema soon becomes asymptomatic, patient compliance is important: starting training too early delays healing. Other treatment options are

1. Shock wave therapy
2. Magnetic field therapy
3. Recurrence prophylaxis: weight reduction if necessary
4. Surgical pressure relief of the bone is rarely necessary
5. PT if necessary (especially for athletes), manual therapy, insoles, etc.
6. Analgesics and other pain therapy such as acupuncture
7. Lymphatic drainage if necessary
8. high-dose vitamin D until 40 ng/ml is reached in the serum. For values below 20 ng/ml: initial 100,000 IU bolus, below 30 ng/ml: initial 60,000 IU bolus. Thereafter 20,000 IU per week. Plus vitamin K1 and boron.
9. No late damage is known and a restitutio ad integrum can be expected. Depending on the severity of the trauma and the size of the edema, healing takes between 3 weeks and 2 years. Certain regions such as the os pubis tend to take longer.