Hemarthrosis is a medical term used to describe the bleeding that occurs in the between the joint. In this condition, blood vessels in the joint are damaged, and they start to bleed out, into the joint spaces.
In major cases, it can be a cause for concern. Because prolonged exposure of blood to the cartilage can damage it. This can even inhibit cartilage components production and delay the cartilage recovery.
It is a common feature observed in Hemophilia patient. If you have pain and swelling in your joints, then you have a higher risk of developing Hemarthrosis.
In this condition, your shoulder and knee joints are first to get hit. Afterward, Elbow, ankle, and hip joints can also be affected.
Table of Contents
What Can Cause Hemarthrosis?
Various hemarthrosis causes are listed below:
1. Trauma
- It is a most common cause of hemarthrosis.
- Internal bleeding can occur by a blunt injury or fracture into your joint. This will cause rapid swelling and in some cases, results in hemarthrosis.
- The pain experience by such trauma is often severe.
- Patient suffering from neuropathy or myelopathy often have impaired sensation. Such patient usually experiences little or no pain. Making it difficult to detect fracture in such patients.
- In injuries showing intra-articular bleeding, synovial fluid (joint fluid) will accumulate rapidly.
- Accumulation of such bloody fluid is also notice in soft tissue injury or osteochondral (cartilage on the end of bones) fracture.
A. Hemarthrosis Of Knee
The knee is a frequent site of injury. Acute hemarthrosis of the knee injury can occur with a forceful twisting of the joint.
Approximately 70% of patients with post-traumatic hemarthrosis is due to the knee injury. The majority of post-traumatic hemarthrosis cases of the knee are:
- ligamentous (connective tissue between two bones of joint) damage
- meniscal (cartilage pad between the thigh bone and shin bone) damage.
B. Anterior Cruciate Ligament (ACL)
ACL tear is the most common cause of knee damage. Meniscal tears of knee occur in 10% of patients. From this, nearly 5% have an ACL tear of a knee.
Severe swelling and muscle spasm will only examine the joint difficult.
Therefore you should do examination immediately after the injury. Delay in the evaluation will only become difficult and hamper with diagnosis precision. And delay evaluation will also require anesthesia.
You should carry out physical examination dealing with the range of joint motion. Full extension of joint should be compared with the opposite uninjured knee.
If you suspect hemarthrosis, you should perform arthrocentesis. But it should be done under strict aseptic condition by a medical professional.
C. Lipohemarthrosis
Lipohemarthrosis is the presence of fat and blood in a joint cavity. Intracapsular fractures or extensive intra-articular soft tissue injury is a major cause of lipohemarthrosis.
D. Plain Film Radiography
Plain film Radiography is the first choice for joints imaging. Here, you can either opt for:
- single fluid-fluid level or
- double fluid-fluid level radiography.
A double level radiograph is much more specific for lipohemarthrosis. Final lipohemarthrosis diagnosis can be confirmed by ultrasonography
If you have a strong suspected of fracture even though radiographs show negative results, you can do computed tomography (CT) scan.
In such conditions, anterior-posterior, lateral, patellar, and tunnel views are recommended for better understanding of knee injury.
E. MRI
Magnetic resonance imaging (MRI) is also a popular choice. It provides helpful information regarding ligamentous and cartilaginous structures. These are typically not visible in plain radiographs or CT scan.
But the first step to treat your injury is to put your leg to rest. So make sure that you are giving your joint enough time to recovery.
You should bandage your knee with an elastic bandage. You can lower your symptomatic pain with anti-inflammatory and analgesics. But confront you doctor before gulping down any medication.
Non-traumatic – Hemarthrosis can also be caused by other reason such as the hereditary disorder or iatrogenic (medical treatment induce) bleeding disorders.
2. Bleeding Disorders
- It mainly occurs in patients who are predisposed to hemorrhage. And also those who are taking warfarin and other anticoagulant.
- It is also associated with knee joint arthroplasty
- Your doctor should consider bleeding disorders when hemarthrosis occurs with minimal or no recollected trauma.
- Your doctor may recommend you complete blood count test. This will also include prothrombin time (PT) and activated partial thromboplastin time (aPTT).
- This bleeding time test will helpful you to detect any platelet disorder if present.
A. Musculoskeletal Hemarthrosis
Musculoskeletal related hemarthrosis is commonly seen in hemophilia patients.
- Hemarthrosis occurs in 75 to 90 percent of severe hemophilia patients (patients having less than 1 percent of the factor activity).
- If you suffer from hemophilia, you will experience your first attack usually between the age of two or three.
- In such cases, bilateral (affects both sides) involvement is a common observation.
- In acute hemarthrosis, your affected joint is painful. It is also swollen and warm, with reduced range of motion.
- In older children and adults, prodromal stiffness is a common manifestation. Some patients also feel a characteristic warm sensation.
- Even though it affects one joint at a time, but it can have multiple bleeding sites.
- Symptomatic relief is rapidly observed after plasma and factor replacement in such cases. Because the effusion (escape fluid) is reabsorbed, mobility returns.
- If you leave hemorrhage untreated, it can develop into an intra-articular damage. It will lead to synovial hypertrophy, fibrosis, and impaired joint movement due to the presence of blood products in joint fluid.
- If you continue to have repeated attacks or persistent hemorrhage longer than six months. It will lead to chronic disabling arthropathy with symptoms mimicking osteoarthritis.
- Growing cartilage is most susceptible to blood-induced damage. Thus, children require aggressive treatment to minimize joint injury.
Five Stages Of Musculoskeletal Damage
Stage 1: Soft Tissue Swelling
Swelling occurs due to direct bleeding into the joint and from adjacent tissues.
Stage 2: Osteoporosis
Development of osteoporosis and epithelial overgrowth occur due to inflammatory hyperemia. It can especially target knee and elbow.
Stage 3: Osseous Lesions
It causes disorganization of the joint. Along with it, even overgrowth of the epiphysis and squaring of the patella (kneecap) is observed. Widening of the articular notch of the knee and the trochlea of the ulna (calf muscle) is observed.
Stage 4: Cartilage Destruction
This stage includes the destruction of joint tissue and narrowing of joint space.
Stage 5: Joint Disorganization
The fifth and final stage occurs in chronic patients. Such patients show complete loss of cartilage spaces. Along with that, they have considerable bony erosion and irregularity in the bone.
Musculoskeletal Hemarthrosis Treatment
X-ray is used as an assessment tool to understand and estimate the joint destruction. MRI and CT are used as an early evaluation technique of the joint damage. It can also be used for subchondral cysts, and cartilage or synovial lesions.
3. Neoplasms (Tumors)
A tumor will not only disrupt the blood vessels in a joint but also develop its blood supply. This can result in hemarthrosis by increasing chances of bleeding.
Most tumors associated with hemarthrosis are benign. Malignant tumors are rare, but they will lead to bloody effusions.
Different types of tumors associated with hemarthrosis are listed below:
A. Synovial Hemangioma
It is a benign vascular tumor. It mainly occurs in a knee joint. It can infiltrate local tissue and adjacent neurologic structures. Synovial hemangiomas may be congenital (from birth). Children compared to adults are more prone to developing intra-articular hemangiomas.
Affected patients have recurrent episodes of knee pain. Recurrent swelling is the next to follow. Whether congenital or not, the tumor mass is composed of many blood vessels.
Despite having so much blood flow towards the tumor, it does not metastasize (spread to other sites in the body). This tumor also rarely undergo malignant (cancerous) transformation.
B. Pigmented Villonodular Synovitis
It is a slow growing, benign tumor. But it can be locally invasive in synovium. It most commonly affects your knee. This can also occur in your hip, ankle, and elbow.
Such Patients experiences, episodic acute attacks of pain and swelling. Those patients also experience locking and catching of the joint due to a mass of tumor.
The synovial fluid in such tumor patients is dark brown due to hemorrhage. You can undergo synovial biopsy for diagnosis of the tumor. Pigmented villonodular synovitis affects few joints, and it is rarely bilateral.
It is usually presented as a monoarticular hemarthrosis. In a majority of cases, on physical examination, such patients show distension of the suprapatellar pouch and a large effusion (escapement of fluid).
It is prominent in 40 % of the cases. This is accompanied by peri-articular erosions. Peri-articular erosion can be detected by plain radiographs.
Pigmented villonodular synovitis show prominent feature on MRI. It shows presence of an intra-articular nodules or masses.
Hence MRI findings are very useful in the diagnosis of PVNS. Treatment of Pigmented villonodular synovitis includes arthroscopic synovectomy. Systemic administration of TNF antagonists was found helpful in some cases.
4. Vascular Disorders
Spontaneous hemarthrosis is the in the patient suffering from degenerative bone disorders like osteoarthritis.
A common reason for Vascular fragility is vitamin C deficiency.
Peripheral arterial aneurysms ruptures can also result in intra-articular hemorrhage.
5. Postoperative
- Following total knee arthroplasty, many patients report hemarthrosis. This episode is also known as Recurrent postoperative hemarthrosis.
- Bleeding in general observed in intra-capsular vascular tissue after joint replacement. This is an unusual complication of knee replacement surgery.
Types Of Hemarthrosis
Hemarthrosis can require into acute bleeding and subacute bleeding.
1. Subacute Hemarthrosis
It is associated with previous synovitis or arthropathy.
In Subacute hemarthrosis, articular bleeding episodes develop within two or three hours.
This subacute hemarthrosis can persist despite adequate hematological treatment.
In this, pain is better tolerated than that in Acute hemarthrosis.
It is commonly associated with slight lack of joint mobility.
Subacute hemarthrosis can recur in months or years. This can result in a state of hemophilic arthropathy.
This is common in young adults, who complain of persistent pain in the affected joint. This type of pain occurs not only when you are in motion, but also when you are at rest.
You may have intermittent episodes of acute pain and also inflammation related to synovitis or articular bleeding.
It is advisable to treat subacute hemarthrosis with hematological substitutive therapy. This includes two to three weeks of immobilization using a semi-flexible splint.
The patient should complete an active, joint-focused exercise program for the joint mobility. You should perform this exercises only under the surveillance of an expert physiotherapist.
2. Acute Hemarthrosis
It occurs in a previously healthy joint.
It is usually felt as a burning sensation in your joint.
It develops within a few hours.
Your joint will becomes inflamed, tense and warm. Because of this, your skin will appear bright red.
The affected joint is painful and has limited mobility.
Your pain will rapidly diminish, but same cannot be said for your inflammation and articular mobility. You tend to recover more slowly.
The degree of inflammation and motion recovery is related to the amount of blood in your joint.
When hemarthrosis does not respond to hematological treatment, septic arthritis can be suspected.
What Are The Signs & Symptoms Of Hemarthrosis?
i) You will notice a warm or tingling sensation in your joints.
ii) Joint pain or swelling will follow next.
iii) Your skin will appear red over the affected joint due to the bleeding occurring in that joint.
iv) Later you may even have trouble moving your affected joint.
What Increases My Risk For Hemarthrosis?
i) Hemophilia or other blood disorder will increase your chances of bleeding.
ii) Use of blood thinner medicines such as aspirin.
iii) A tumor, neuropathy, or myelopathy can also disturb the blood vessels.
iv) A pre-existing condition such as Osteoarthritis or septic arthritis
v) Procedure such as Arthroplasty (surgery) done on your knee joint.
vi) Presence of cartilage or vascular damage
vii) Suffering from sickle cell disease or scurvy (vitamin deficiency).
Complications
Haemarthrosis can cause cartilage damage and inhibit its regeneration. This cartilage damage if not controlled can lead to progressive degenerative arthritis.
So this a terrible bad news for patients already suffering from such cartilage degenerative conditions and osteoarthritis patients.
When Should I Seek Immediate Care?
- If you have the onset of a new or worsening of already existing joint pain.
- If you feel that your joint pain is radiating to other muscle or surrounding area.
- If you cannot move your affected joint.
How Is Hemarthrosis Diagnosed?
The Doctor you visit will first take into account your medical history. Then he will perform a physical examination. Do inform your doctor if your joint was injured or if you had a recent knee arthroplasty. Also, inform him/her if you are on any blood thinner medicine.
Your doctor may perform a joint aspiration (arthrocentesis) test. This test can act as a definitive diagnosis for Hemarthrosis. Joint aspiration should always be done in aseptic conditions to avoid recurrence or septic arthritis.
Your doctor will first inject a needle into your affected joint and draw off some joint fluid. This fluid later undergoes full laboratory analysis.
Reddish, pinkish or brownish joint fluid is an indication of hemarthrosis. If your joint fluid is cloudy, it is a sign of abnormality.
This is also suggestive of inflammation or an infection of some kind. Bloody joint fluid is also an abnormal sign. It may be caused by trauma to the joint.
Your joint fluid is examined under the microscope for the presence of blood cells, crystals, and bacteria. No or few blood cells are present in the normal synovial fluid. Large numbers of red blood cells in the joint fluid would indicates bleeding.
While large numbers of white blood cells point towards an infection or inflammatory.
Presence of bacteria is a confirmation of infection. The joint fluid is also tested for the amount of glucose, protein, and lactic dehydrogenase (LDH).
i) Glucose – less than 40 mg/dl
ii) Protein – greater than or equal to 3 g/dl
iii) LDH – greater than 333 IU/L.
Presence of any of this above abnormal results will only indicate the presence of an infection or inflammation.
Another test performed on your joint fluid is to keep it standing for one hour in the test tubes. It is then observed for formation of a fibrin clot.
Presence of any clot would indicate that there is a problem with the synovial membrane (a layer of tissue that lines the joint).
Afterwards, of your joint aspiration, Your doctor may then tell you to do an MRI or ultrasound of the joint for the clear image of your damage. Make sure never to enter the MRI room wearing any metal on your body.
Can Hemarthrosis Be Successfully Treated?
Treatment for hemarthrosis depends on the cause. The objectives of the treatment are to avoid:
i) Muscular atrophy
ii) Maintain an adequate degree of articular mobility
iii) Control the recurrence of hemarthrosis and
iv) Recover joint function if possible.
In acute cases of hemarthrosis, clotting factors may be given. Your doctor can suggest you to use crutches or a sling to rest your affected joint.
You should also limit your movements as much as possible to rest your joint. But also don’t overdo it. Because long time without movement can cause muscle contracture (shortening).
While joint aspiration is an option for large bleeds. But it should be done within two days of the bleed. This as to prevent the damage.
If you are on any blood thinners, please inform your doctor. Your doctor will then either lower your dose or ask you to completely stop taking it until your condition improves. But in any case:
i) Do not stop taking your medicine without consulting your doctor. Because this can be life-threatening.
ii) In severe cases, surgery is an option. In surgery lining from the joint, or bone near the affected joint is removed.
In patients suffering from hemophilia, hemarthrosis is a major cause of disability. This occurs due to hemophilic arthropathy.
Such patients are required to undergo synovectomy or joint replacement. They also requires increase in medical therapy to prevent any further bleeding incidents.
Some osteoarthritis patient may have experienced recurrent hemarthrosis episodes after knee arthroplasty. In such cases, Synovectomy (removal of joint lining), meniscectomy and osteotomy have been used successfully.
Ablation is another technique known to provide debridement limited to the diseased tissue. If all this option is not working, Joint replacement could be the only treatment.
In this procedure, all or part of a joint is artificially replaced. In any case, your doctor is the best judge to make an appropriate assessment and offer treatment recommendations.
For recurrent hemarthrosis Radionuclide synovectomy is a straightforward procedure to perform. But it should be performed as soon as possible to halt the long-term damage.
Radioactive synoviorthesis is the “gold standard” for the treatment once hematologic treatment fails. But this procedure is of high cost due to use of radioactive materials.
The most serious potential problem with radioactive synoviorthesis is skin burns. It is caused by extravasation of radioactive material from the joint at the time of injection.
In such cases, rest and nonsteroidal anti-inflammatory drugs commonly solve the problem.
Joint Replacement Surgery To Treat Hemarthrosis
Major surgeries can always be a life-changing event. So it’s better to gather all available information regarding it to make a sound decision.
What Exactly Is Joint Replacement Surgery?
Joint replacement surgery is removing a damaged joint and replacing it with a new one. An orthopedic surgeon is the one who will perform this surgery.
Depending on your level of damage a surgeon may remove your whole joint or only replace the damaged parts.
What Is A New Joint Like?
The artificial joint is called prosthetic joints. They are made of plastic, metal, or ceramic parts. It can be cemented into the place, and your bone will grow into it. A combination of both cemented and uncemented methods can be used to keep the new joint in place.
A cemented joint is often used for older people. In general elderly people do not move around as much as a young adult. The cement will hold the new joint to the bone.
Young adult lives a more active life and has good bone quality than elderly. So an uncemented joint is more popular choice among younger patients.
Since there is no cementing mold for a bone to grow, It takes longer for the bone to attach. Hence it also requires a longer time for the bone to heal and grow.
New joints have a life expectancy of at least 10 to 15 years. Therefore, younger patients might require replacing the damaged joint more than once.
Do I Need to Have My Joint Replaced?
This decision recites upon your doctor. Your doctor will first give you some medicines and vitamin supplements. Your doctor may also ask you to undergo some physical therapy. If none of this works, your doctor may suggest an osteotomy.
It is a surgery in which a surgeon will “aligns” your joint. Here, the surgeon will cut the bone around your joint. This will help to improve your alignment. This is a simpler procedure than replacing a joint.
But it will take the longer time to recover.
What Happens During Surgery?
First, the surgical team will give you an anesthetic agent. This anesthetic agent may use knockout your whole body to sleep (general) or only a part of your body (regional).
Duration of your surgery will depend on how badly your joint is damaged. To replace a knee or a hip, it takes about 2 hours or less unless there is complication.
After surgery, you will be moved to a recovery room. There you will be kept for about 1 to 2 hours. Until you are fully awake or your numbness has goes away.
What Happens After Surgery?
After surgery, you kept under observation in hospital for a few days. Elderly or disability patient is required to spend more time in the hospital.
It may extend up to several weeks in an intermediate-care facility.
After hip or knee replacement, you will often stand or begin walking the same day after the surgery. In the initial stage, you will require a walker or crutches to walk. You may have some temporary pain in the new joint.
Because your muscles are weak from not being used. The pain can be helped with medicines and should end in a few weeks or months.
You are required to underwent Physical therapy after the surgery to help strengthen your muscles around the new joint. This will also help you to regain motion in your joint.
A physical therapist will give you range-of-motion exercises to perform.
No surgery is risk-free.
So here are some possible problems experienced by patients:
i) Infection
Areas around the new joint may get infected. It can even occur years later your surgery. Minor infections in the wound occur immediately after surgery. This can be treated with drugs. But severe deep infections may require a second operation to treat the infection.
ii) Blood Clots
Blood clots will cause swelling and pain near your joint. So your doctor may suggest you the blood thinner or special exercise to reduce your blood clots.
iii) Loosening
Loosening of the new joint will cause you pain. If the new joint is loosened too much, then it may require another operation to reattach or tighten the joint.
iv) Dislocation
This commonly observed in hip joint replacement. In most cases, this can be corrected without surgery just by wearing a brace.
v) Nerve And Blood Vessel Injury
Nerve and blood vessel injury during surgery is a rare occurrence. If such damage occurs, it often improves and disappears on its own.
What To Do After You Underwent Surgical Procedure To Treat Hemarthrosis?
Joint aspirations of the elbow, knee, and ankle are simple procedures than other joints such as the hip joint. So they can be done at an outpatient clinic.
While joints such as shoulder and hip joint aspirations require sedation and radiographic control by an image intensifier. They are surgical procedures done in an operating room with anesthetic, by an orthopedic surgeon.
Management Of Particular Joint After Surgery
1) After any of such procedures Bed rest (one day or as directed by a surgeon) is mandatory. This is followed by avoidance of lifting and carrying heavy items until the bleeding has resolved. Which is usually 4 to 5 days
2) You should include the use of crutches to reduce pressure on your affected joint.
3) For the knee, a compressive bandage supplemented along with a long-leg posterior plaster splint can be used.
4) For the ankle joint, a short-leg posterior plaster splint is recommended.
5) Sling (shoulder) or a long-arm posterior plaster splint (elbow) can be used for the upper limb. It will provide sufficient rest and support to your joint.
6) Ice should not be applied directly to the skin. It should be wrapped in a thick towel. Because the prolonged application can cause skin damage.
7) Your doctor will prescribe you analgesic agent depending on the degree of your pain.
8) Paracetamol or a combination of paracetamol and dextropropoxyphene is administered in major cases.
9) Aspirin-containing products or nonsteroidal anti-inflammatory drugs must be avoided.
What Can I Do To Manage Hemarthrosis?
- Talk to your doctor. Your healthcare provider is the person with correct information. Do not take any medicine or supplement without talking before your healthcare provider.
- Return to activities as directed. You must rest your joints until directed by your doctor. Also, contact your doctor before resuming any sports.
- Go to physical therapy as directed. Your healthcare provider will recommend you with some physical therapy sessions. A physical therapist will help you to recover fast by improving your joint’s range of motion.
- Exercise as directed. Your physical therapist will provide you with certain exercise. This would help to strengthen your muscles and recover your joints faster.
- Apply ice to the joint as directed. Ice helps to reduce pain and swelling. Ice will also prevent further tissue damage. Use an ice pack, or put ice in a plastic bag or cover it with a towel. Apply on your affected joint for 15 minutes every hour, or as otherwise directed.
When Should I Contact My Healthcare Provider?
- Your pain does not get better or worsen after taking your pain medication.
- You have questions or concerns about your medicine, exercise or condition.
Final Talk
Hemarthrosis is a severe condition especially if you are suffering from osteoarthritis and hemophilia. Hemarthrosis is manageable without surgery if notice early on. Contact your doctor, as soon as you detect that you are showing signs of hemarthrosis.
Once detected, follow the regimen and preventive measures as described by your doctor. An early and progressive physical therapy will help you to recover the full range of your movements faster.
