Introduction

Hemarthrosis

Bleeding into a joint cavity.

• M/C joints affected: Knees, ankles and elbows
• Lipohemarthrosis: Presence of fat and blood in the joint cavity
  • Stems from marrow fat leakage into the synovial fluid usually due to intra-capsular fractures or extensive intra-articular soft tissue injury (ligamentous or meniscal).
    
  • Lipohemarthrosis of the knee: Suspected cases (descending order):
    • Tibial plateau fracture (lateral plateau fractures often associated with ACL and MCL injuries)
    • Tibial spine avulsion (anterior attachment point of ACL and more common in pediatric patients who have tougher ligaments than bones)
    • Femoral condyle fracture (uncommon, however associated with popliteal artery and fibular nerve injury)

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Aetiology

Traumatic haemarthrosis (M/C cause):

Typically occurs in the setting of intra-articular injury with ligamentous, osseous, and/or
cartilage damage leading to a bloody synovial fluid collection.

• Traumatic hemarthrosis of the knee (M/C traumatic haemarthrosis):
  • Anterior cruciate ligament (ACL) injury (75% cases)
  • Lateral patellar dislocation (M/C structural injury associated with traumatic hemarthrosis of the knee)
  • Meniscal tear
  • Lipohemarthrosis often associated in:
    • Tibial fractures
    • Plateau fractures
    • Chondral fractures

Non-traumatic haemarthrosis:

• Hereditary bleeding disorders:
  • Haemophilia (80% cases) and other inherited coagulation factor deficiency disorders.
    • Hemarthrosis is M/C musculoskeletal manifestation of haemophilia
• Acquired bleeding disorders:
  • Advanced liver/renal disease
  • Vitamin K deficiency
  • Disseminated intravascular coagulation (DIC)
  • Anticoagulation medication use
• Other causes:
  • 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 lateral meniscus)
  • Neoplasms: Benign synovial hemangiomas, pigmented villonodular synovitis, any malignant tumour/metastasis near a joint cavity

Postoperative hemarthrosis:

• Freuently associated with total knee arthroplasty (due to the development of intra-capsular vascular tissue which subsequently causes bleeding into the joint after joint replacement surgery)
• Uncommon complication following arthroscopy

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Clinical features

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Complications

• Severe/recurrent haemarthrosis:
  • Destruction of intra-articular cartilage
  • Degenerative arthritis
• Toxic effects of blood → Intra-articular damage → Synovial hypertrophy & fibrosis
• Haemophiliacs:
  • Repeated/prolonged attacks → Target Joints → Chronic disabling arthropathy (due to internal joint derangement and impaired joint movement)

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Diagnosis

Investigations

Arthrocentesis:

• Synovial fluid: Red, pink, or brown (depending on the cause of bleeding)

Joint aspirate fluid analysis:

Differentiate simple effusion, hemarthrosis, lipohemarthrosis, and septic arthritis.

• Lipohaemarthrosis: Lipid globules in synovial fluid
• Traumatic haemarthrosis: Initial synovial fluid aspirate is non-bloody but bright red blood soon appears after withdrawing fluid
• True haemarthrosis: Typically does not clot due to fibrinolysis compared to a bloody aspirate from traumatic aspiration that does coagulate

Imaging

Plain film radiology:

• Lipohaemathrosis: Cross-table lateral view of leg

• CT scan
  • Better resolution

MRI:

Diagnose ligamentous or other soft tissue injury as the cause of hemarthrosis.

• Ultrasound (US)
  • Identify and characterize intra-articular fluid collections

Histopathology

Early disease characteristics:

• Synovial hypertrophy & fibrosis (similar to rheumatoid arthritis)

Late disease characteristics:

• Disruption of cartilage & subchondral cyst formation (due to interosseous bleeding)
  • Intraarticular bleeding has direct toxic effects leading to the destruction of cartilage and bone.

Differntial diagnosis

• Septic arthritis
• Lyme disease
• Tuberculosis
• Gout (monosodium urate crystals), pseudogout (calcium pyrophosphate crystals)
• Rheumatoid arthritis
• Systemic lupus erythematosus (SLE)
• Leukaemia
• Seronegative spondyloarthropathies (psoriatic arthritis, reactive arthritis, inflammatory bowel disease arthritis)
• Osteoarthritis

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Management

Intial treatment (acute haemarthrosis):

• Immobilization, ice, and compression
• Analgesia (pain control)
• Arthrocentesis with aspiration from a joint (both diagnostic & therapeutic by reducing pressure from the effusion)

Special cases:

• Haemophiliacs:
  • Hemophilia A: Factor VIII
  • Haemophilia B: Factor IX
  • Other drugs: Glucocorticoids, NSAIDs (avoid drugs with anti-platelet activity)
• Recurrent postoperative hemarthrosis: Revision angioplasty
• Ruptured aneurysms: Vascular surgery intervention or arterial embolization
• Benign tumours: Arthroscopic or surgical synovectomy
• Chronic synovitis or arthropathy: Joint surgery