Soft tissue hematomas on ultrasound: a case-based review and practical guide to diagnosis

Soft tissue hematomas are frequently encountered in both emergency and outpatient settings and often present a diagnostic challenge due to their variable ultrasound appearance and overlapping features with other soft tissue pathologies. Ultrasound is the first-line imaging modality for their evaluation, offering real-time, radiation-free assessment. The sonographic appearance of hematomas is influenced by the stage of evolution, etiology, and anatomical location, which can complicate their differentiation from other entities, particularly when clinical history is unclear or imaging findings are atypical. This article provides a comprehensive review of the sonographic features of hematomas, categorized by etiology (spontaneous, iatrogenic, traumatic), and supported by a series of illustrative clinical cases. These cases highlight key imaging patterns and clinical scenarios that commonly arise in routine practice and underscore the importance of correlating ultrasound findings with clinical evolution and patient a history, especially in diagnostically ambiguous presentations. Diagnostic workflows, practical scanning tips, and key features for differential diagnosis are reviewed, including abscesses, seromas, soft tissue sarcomas, and ruptured Baker's cysts. Emphasis is also placed on integrating clinical context with imaging findings, particularly in anticoagulated or immunocompromised patients. Recognizing subtle sonographic signs and applying a structured approach can greatly improve confidence in diagnosis. This review aims to equip radiologists, sonographers, and clinicians with a structured, practical framework for the ultrasound evaluation of soft tissue hematomas, promoting diagnostic accuracy and optimal patient care.