Contents
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)
- 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).
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
- Haemophilia (80% cases) and other inherited coagulation factor deficiency disorders.
- 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

- 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)

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