Musculoskeletal System ORGAN SYSTEMS




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)


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


  • 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)




  • 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


Plain film radiology:

  • Lipohaemathrosis: Cross-table lateral view of leg
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,
  • CT scan
    • Better resolution


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

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


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


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)
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.

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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