Hemarthrosis

Hemarthrosis is a term that refers to bleeding into a joint or joint space. This occurs when blood from damaged blood vessels builds up in the joint cavity, resulting in joint pain, swelling, pressure, and restricted range of motion. Over time, the accumulation of blood in this restricted space and resulting chronic inflammation can lead to permanent joint damage. Hemarthrosis may affect any joint in the body but most commonly affects the knees, elbows, shoulders, and hips. 

Hemarthrosis can be caused by a variety of etiologies but is most commonly due to traumatic causes, including knee injury (e.g. anterior cruciate ligament tears) and fractures. Rarely, hemarthrosis can occur as a postoperative complication. Non-traumatic causes include bleeding disorders, like hemophilia, an inherited disorder where the body does not form blood clots properly; infection (e.g., septic arthritis); complications from vascular disorders (e.g., rupture of an aneurysm); inflammatory conditions (e.g. gout); medications, such as anticoagulants (e.g., warfarin, which inhibit clotting factors); toxins (e.g., rat poison); nutritional deficiency (e.g., vitamin K, which is essential for the production of clotting factors); hemangioma (i.e., benign tumors of blood vessels); and rarely, degenerative arthritis, presumably from degenerative tears. 

Symptoms of hemarthrosis typically vary according to etiology but commonly include joint pain or discomfort that ranges from mild to severe depending on the chronicity of the bleeding. For example, acute hemarthrosis is typically very painful as the joint cavity is unable to accommodate the rapid expansion of blood in such a short span of time, whereas chronic hemarthrosis may be less painful due to desensitization of nerve endings over time. Individuals with hemarthrosis may also experience joint stiffness, swelling, warmth, and reduced range of motion. Hemarthrosis due to joint infection may present with infectious symptoms, like fever and chills. 

Diagnosis of hemarthrosis begins with a thorough history, which elicits the timeline and chronicity of the individual’s symptoms. A medical and family history can exclude any potential hereditary clotting and bleeding disorders. A physical exam can help localize the affected area(s) and assess the range of motion. Further laboratory blood tests can be ordered to differentiate the various etiologies, including a complete blood count (CBC) for infection and coagulation studies for bleeding disorders or anticoagulant-induced hemarthrosis. 

Imaging tests, such as plain film X-rays, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), can help assess the extent of bleeding and any underlying structural abnormalities (e.g., fracture). Imaging may show tissue swelling, joint effusion, or chronic bone and cartilage erosions. 

The diagnosis is ultimately made using joint aspiration, a therapeutic and diagnostic procedure that removes synovial fluid and blood around the joint. The aspirated joint fluid may either be uniformly sanguineous or a rusty brown color. If the etiology is unclear, the aspirated joint fluid can also be sent for further infectious (i.e., gram stain, culture) and neoplastic (i.e., cytology) evaluation. 

While the treatment of hemarthrosis depends on the etiology and severity of symptoms, all modalities are typically aimed at reducing pain and limiting further joint injury. Individuals are recommended to rest or immobilize the affected joint and avoid activities that exacerbate pain and/or swelling. The application of ice and compression to the joint can help reduce pain and swelling. After 48 to 72 hours, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can also be helpful in alleviating pain and reducing inflammation. When the initial symptoms improve, the addition of a physical therapy rehabilitation program can improve joint mobility and strength. Treatment should also address the underlying cause, especially if other health conditions are involved. For example, in the case of hemophilia, a blood transfusion containing clotting factors can be helpful in stopping the bleeding in the acute setting. In severe, chronic cases in which extensive joint damage has occurred, a surgical joint replacement may be another option. 

Hemarthrosis is a term that refers to bleeding into a joint or joint space that occurs when blood from damaged blood vessels builds up in the joint cavity, resulting in joint pain, swelling, pressure, and a restricted range of motion. Hemarthrosis is caused by a variety of traumatic (e.g., surgery) and non-traumatic (e.g., bleeding disorders, infection, vascular disorders, toxins, nutritional deficiency, degenerative arthritis) causes. Common signs and symptoms commonly include joint pain, stiffness, and swelling. The diagnosis is made via a thorough medical history and joint aspiration evaluating the synovial fluid.  Imaging tests, such as ultrasound, CT, and MRI, can also be helpful in diagnosing hemarthrosis. The goals of treatment are to reduce pain and limit further joint injury, and options include nonpharmacologic measures (e.g., rest and elevation of the joint), pharmacotherapy (e.g., NSAIDs, acetaminophen), and physical therapy.