Hemarthrosis is a condition that occurs as a result of bleeding into a joint cavity.
The most common joints affected are the knees, ankles, and elbows, although it can also occur in the hip, shoulders, and wrists.
Causes of Hemarthrosis
Blood Coagulation Disorders
Recurrent hemarthrosis is a frequent problem in hemophilia, a disorder marked by clotting factor VIII or IX being defective or missing.
However, many other causes can lead to hemarthrosis.
Occasional episode of hemarthrosis heals very well without any residual deformity or joint sequelae.
But an hemarthrosis occurring recurrently for long periods, over the time can cause permanent damage in a person’s joint like joint deformity or stiffness or degenerative changes.
The severity and frequency of the bleeds will determine how likely a person is to develop permanent damage. Joint bleeding destroys the cartilage leading to painful joint and reduced movement.
Blood-thinning drugs, known as anticoagulants could also tilt the balance toward spontaneous bleeding and lead to bleeding in a joint.
Thrombocytopenia for any other reason may also lead to bleeding tendencies.
Osteoarthritis is rarely responsible for bleeding in the joint.
Bleeding may occur in bacterial arthritis due to increased vascularity though the amount of bleed is scant rather than copious. Often the blood is mixed with the exudate that fills the joint.
A ligament passing through joint may get injured and lead to hemarthrosis. The severity of the injury would determine the severity of hemarthrosis.
Most often this is seen in knee joint but others like elbow and ankle may also present with this. There is typical history of strain on the joint following which swelling resulted.
Joint dislocations would also lead to some amount of hemarthrosis.
Lipohemarthrosis indicates presence of fat cells and blood in the joint. It is often seen after subchondral fractures. In older time, when imaging was not sophisticated, this was taken as sign for presence of subchondral fractures.
Aneurysms of vessels have been reported to cause hemarthrosis. So are AV fistulas.
There are a few tumors that are associated with blood in the joint.
Pigmented Villonodular synovitis, Hemangioma and synovioma are few examples.
Clinical Features of Hemarthrosis
Painful joint swelling is the most common presentation.
Depending on the causative factor, the patient may have history of trauma or the swelling is spontaneous. In hemophilia, there would be history of similar previous episodes.
Significant history indicating some condition may be present
In case of spontaneous swellings the patient must be asked about any anticoagulant therapy.
A baby with joint swelling who is irritable or crying for no reason could be early sign of spontaneous hemophilic hemarthrosis. An older child may refuse to bear weight on the affected life.
Fever and presence of systemic signs in a child should make the physician consider a differential of
There is no particular lab test for hemarthrosis.
Synovial fluid obtained from a patient with a hemarthrosis may appear red, pink, or brown depending on quantity of blood and freshness of bleed.
A true bloody effusion usually fails to clot due to chronic fibrinolysis, while blood from a traumatic aspiration generally does coagulate.
The aspirate from a patient with hemarthrosis will generally exhibit xanthochromia [yellow discoloration] from lysis of the resident erythrocytes.
Although diagnosis of hemarthrosis usually requires joint aspiration, arthrocentesis is generally not required for diagnosis when the underlying cause is known with confidence.
When aspiration is done, the fluid may be subjected to cytological and biochemical analysis.
CBC, CRP and ESR are done to differentiate from septic arthritis.
X-ray is beneficial to rule out bony injuries. X-rays also reveal large swellings.
In other cases, MRI is able to delineate the pathology and reveal joint status.
Arthroscopic evaluation of the knee is not needed in every patient with an acute hemarthrosis.
For acute treatment splintage of the limb is done and opoid pain relieving drugs are given. NSAIDs should be avoided especially in cases of bleeding due to blood coagulation disorders.
The splint provides rest and helps in healing.
In case of hemophilia, appropriate measures should be done to control further bleeding. These include compression bandage and clotting factor replacement.
Coagulation disorders need to be treated aggressively.
Definitive treatment of the condition depends on the causative disease.
Hemarthrosis per se, in absence of joint problem does not require any further treatment. Treatment of the cause would relieve patient of hematoma.
Symptomatic and supportive treatment is warranted till then.
Very big hemarthrosis may be drained and compression bandage is applied.
Synovectomy or removal of synovium may be considered as long-term solution for hemophilia.
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