Hemarthrosis is bleeding into a joint cavity. Its presence can be suspected based upon patient history, physical exam, and multiple imaging modalities; however, the best way to diagnose hemarthrosis is with arthrocentesis with synovial fluid analysis. Lipohemarthrosis the presence of fat and blood in the joint cavity.
Causes of Hemarthrosis
Many diseases and disorders can present with hemarthrosis. However, categorization is generally divided into traumatic, non-traumatic, and postoperative. Traumatic injury is the most common cause of hemarthrosis.
- Non-traumatic hemarthrosis – can be caused by a variety of bleeding disorders that are either hereditary or acquired. Hereditary bleeding disorders include hemophilia and other inherited coagulation factor deficiency disorders. Examples of acquired bleeding disorders include advanced liver or renal disease, vitamin K deficiency, disseminated intravascular coagulation, or anticoagulation medication use. Other more rare causes of non-traumatic hemarthrosis include the following:
- Neurologic – Reflex sympathetic dystrophy, diabetic neuropathic arthropathy
- Infectious – Septic bacterial arthritis
- Vascular – Vitamin C deficiency, ruptured peripheral artery aneurysms, osteoarthritis (degenerative tears of peripheral arteries associated with a posterior horn of the lateral meniscus)
Post-operative recurrent hemarthrosis is frequently associated with total knee arthroplasty and has also been described as an uncommon complication following arthroscopy.[rx]
Symptoms of Hemarthrosis
Symptoms of hemarthrosis may include:
- Bleeding gums after brushing teeth or dental work
- Bleeding longer or more than usual after injury or surgery
- Blood in the urine
- Bruising easily
- Deep bruising due to bleeding in the muscle after routine shots or minor injuries
- Frequent nosebleeds
- Joints that feel warm or have a tingling sensation
- Pain and swelling at the joint
- Prolonged bleeding in babies after the umbilical cord is cut or after a male is circumcised
- Refusal to move an arm or leg because of joint pain
Diagnosis of Hemarthrosis
Histopathology
The histopathology of hemophilic arthropathy can be divided into early and late disease characteristics. In early disease, there is synovial hypertrophy and fibrosis which displays changes similar to rheumatoid arthritis. Progression of the disease shows disruption of cartilage and subchondral cyst formation from interosseous bleeding. The intra-articular bleeding has direct toxic effects leading to the destruction of cartilage and bone. Iron in the form of ferric citrate stimulates human fibroblast cells to proliferate. Studies involving mice imply hemarthrosis leads to blood vessel hyperplasia which may explain the predisposition for hemophiliacs to experience recurrent intra-articular bleeding.[rx][rx]
Toxicokinetics
Rodenticides are superwarfarins that, upon ingestion, can cause spontaneous bleeding including acute hemarthrosis. Patients can be asymptomatic up to 72 hours after ingestion. Gastrointestinal symptoms can be present early in the course of poisoning, and spontaneous bleeding can present as early as 8 hours after exposure.
History and Physical
In most patients, especially those without pre-existing neurologic sensation dysfunction or bleeding disorders, a traumatic incident is known to the patient, and the cause of the hemarthrosis is suggestive from history. Following an injury with intra-articular damage, the swelling from bloody synovial fluid accumulation is typically rapid within a few hours. Pain is a significant component, however, may take time to develop, or may be minimal or absent in patients with pre-existing impaired sensation. The range of motion of the affected joint is typically significantly reduced.
Certain locations and types of injury following a traumatic incident are more likely to develop a hemarthrosis. Intra-articular elbow fractures including those of the radial head are universally associated with hemarthrosis. The knee is a frequent site of hemarthrosis with the most common mechanism being forced twisting of the loaded joint. The majority of these post-traumatic hemarthroses are from ligamentous and meniscal damage. Anterior cruciate ligament (ACL) tears are the most common, representing 70% of post-traumatic hemarthrosis of the knee, followed by 10% to 15% patellar subluxation/dislocation injuries, 10% from the meniscal tear, 2% to 5% from osteochondral fracture fragments, and 5% represented from other injuries including posterior cruciate ligament (PCL) or capsule tears. Depending on the size and kind of injury, tenderness to palpation of the joint lines or patella will be present and clinical tests for joint laxity may be positive.[rx]
If hemarthrosis occurs spontaneously or after minimal trauma, bleeding disorders such as hemophilia should be suspected. Hemarthrosis is the most common musculoskeletal manifestation of hemophilia. Severe hemophilia (less than 1% of normal factor activity) causes hemarthrosis in 75% to 90% of patients with the first attack typically occurring between ages 2 to 3. Any joint can be affected; however, the knee is the most common site. Patient history regarding family history, extensive or prolonged bleeding during or after surgery, use of anticoagulant medications, and diet habits should be elicited to help determine whether the presence of a bleeding diathesis exists.[rx]
Clinical presentation of hemophilia with hemarthrosis can vary by age. In adults and older children, there is typically a prodromal stiffness or tingling which precedes pain and swelling. In infants, signs of hemarthrosis may include irritability and decreased use of the affected limb. Bleeding into the hip joint is concerning due to the greater risk of increased intra-articular pressure and osteonecrosis of the femoral head. In hemophilic hemarthrosis, one joint is typically affected at a time; however, bilateral joint involvement is possible.[rx][rx]
Evaluation
A suspected hemarthrosis can be evaluated by plain radiographs, computed tomography (CT) scan, or magnetic resonance imaging (MRI). The preferred initial imaging modality is plain film radiology of the involved joint and surrounding bones. If a fracture is not seen but strongly suspected, further evaluation with a CT scan is warranted. MRI may be able to diagnose ligamentous or other soft tissue injuries as the cause of hemarthrosis. Ultrasound (US) in the right clinical setting can help identify and characterize intra-articular fluid collections.[rx]
Also tell him if you are taking blood thinner medicine. You may also need any of the following:
- Aspiration – is a procedure used to take fluid from the joint to be tested for blood. This procedure is also called arthrocentesis. Your healthcare provider may also use aspiration to treat your hemarthrosis.
- MRI or ultrasound – pictures may show joint damage or other problems. Do not enter the MRI room with anything metal. Metal can cause serious damage. Tell the healthcare provider if you have any metal in or on your body.
| Type | WBC per mm3 | % neutrophils | Viscosity | Appearance |
|---|---|---|---|---|
| Normal | <200 | 0 | High | Transparent |
| Osteoarthritis | <5000 | <25 | High | Clear yellow |
| Trauma | <10,000 | <50 | Variable | Bloody |
| Inflammatory | 2,000-50,000 | 50-80 | Low | Cloudy yellow |
| Septic arthritis | >50,000 | >75 | Low | Cloudy yellow |
| Gonorrhea | ~10,000 | 60 | Low | Cloudy yellow |
| Tuberculosis | ~20,000 | 70 | Low | Cloudy yellow |
| Inflammatory = gout, rheumatoid arthritis, rheumatic fever | ||||
Treatment of Hemarthrosis
Treatment of hemarthrosis includes interventions that are helpful for any patient who develops acute hemarthrosis for any reason along with specific treatments that target the underlying cause of the hemarthrosis.
- Initial treatment of any acute hemarthrosis includes immobilization, ice, and compression. Analgesia for pain control may be required in the acute period, especially to obtain a radiographic evaluation.
- Arthrocentesis with aspiration from a joint can be both diagnostic and therapeutic by reducing pressure from the effusion.[rx]
- Special treatment considerations should be given for hemophiliacs presenting with acute hemarthrosis. Coagulation factors specific to hemophilia should be infused promptly at the first sign of joint bleeding (including the prodromal stiffness or tingling phase prior to pain and swelling) ideally within 2 hours of bleed identification. For bleeding into the hip, a target joint, or bleeding associated with trauma, higher factor activity levels of 80% to 100% are targeted; for hemophilia A give 50 units/kg of factor VIII and for hemophilia B given 100 to 120 units/kg of factor IX. For hemarthrosis in peripheral joints such as knees, elbows, or ankles, the factor activity level should be raised to at least 40% to 50%; for hemophilia A give 25 units/kg of factor VIII and for hemophilia B give 50 to 60 units/kg of factor IX.
- Medications with anti-platelet activity such as non-steroidal anti-inflammatory agents (NSAIDs) should be avoided. Arthrocentesis is not necessary to diagnose joint bleeding in patients with known hemophilia; however, if arthrocentesis is deemed necessary to rule out a septic joint or reduce pressure from accumulated blood, it should only be performed after the factor has been infused to raise the specific factor levels.
- In hemophiliacs with target joints who undergo repeated hemorrhage, a short course of glucocorticoids has been found beneficial to reduce pain and swelling associated with synovial inflammation, as long as no signs of septic arthritis exist. Joint surgery for chronic synovitis or arthropathy may be indicated including synovectomy for recurrent bleeding or joint replacement for extensive joint damage.[rx][rx]
Differential Diagnosis
The differential diagnosis of an acute joint effusion includes other notable disease processes. Conditions which can be mistaken for an acute hemarthrosis include:
- Septic arthritis
- Lyme disease
- Tuberculosis
- Gout (monosodium urate crystals)
- Pseudogout (calcium pyrophosphate crystals)
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Leukemia
- Seronegative spondyloarthropathies (psoriatic arthritis, reactive arthritis, inflammatory bowel disease arthritis)
- Osteoarthritis
This may be especially true if associated with trauma is remote, unclear, or unknown. Arthrocentesis with synovial fluid analysis, diagnostic imaging, and further laboratory workup specific to these other disease processes may be required to differentiate between the causes of an acute joint effusion.
Complications
Severe or recurrent hemarthrosis can lead to the destruction of intra-articular cartilage and degenerative arthritis. The toxic effects of blood cause intra-articular damage leading to synovial hypertrophy and fibrosis. In hemophiliacs, these joints which undergo chronic inflammatory changes from repetitive attacks of hemarthrosis are called “target joints.” Repeated or prolonged attacks can lead to chronic disabling arthropathy due to internal joint derangement and impaired joint movement. Chronic arthropathy affects approximately 20% of hemophiliacs. Recurrent hemarthrosis in hemophiliacs can be prevented with the administration of prophylactic coagulation factors.[rx][rx]
References
