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Musculoskeletal System ORGAN SYSTEMS

Haemarthrosis

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)

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

Clinical features


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)

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
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Lipohemarthrosis (blood and fat in the joint space) seen in a person with a subtle tibial plateau fracture. The arrow indicates a fluid level between the upper fat component and the lower blood component. | James Heilman, MD – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15376768
  • 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

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)
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The Western Australia protocol of joint aspiration (pediatric rheumatologist washing out all acute hemarthrosis of large joints promptly and then instilling intraarticular (IA) corticosteroids) | Note the extension tubing and 3-way tap to avoid manipulation of the needle. | Manners, P. J., Price, P., Buurman, D., Lewin, B., Smith, B., & Cole, C. H. (2015). Joint Aspiration for Acute Hemarthrosis in Children Receiving Factor VIII Prophylaxis for Severe Hemophilia: 11-year Safety Data. The Journal of Rheumatology, 42(5), 885 LP-890. https://doi.org/10.3899/jrheum.141236

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

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