Hemarthrosis is a hemorrhage in the joint cavity. Occurs due to rupture of vessels supplying blood to intra-articular structures. It is more often observed in the knee joint. It can be traumatic or non-traumatic. With hemarthrosis, the joint increases in volume and becomes spherical, pain and fluctuation (swelling) occur. The diagnosis is made on the basis of an examination. To clarify the cause of the pathology, radiography, MRI, CT and other studies may be prescribed. Treatment – puncture of the joint, application of a plaster cast.
Hemarthrosis is the accumulation of blood in the joint. Most often develops with injuries. The second most common is hemarthrosis in hemophilia. Hemorrhage can occur in any joint, but in most joints it is usually small and resolves on its own, without special therapeutic measures. The exception is the knee joint, when hemarthrosis occurs in such cases, punctures are usually required. The treatment is carried out by specialists in the field of traumatology and orthopedics.
Hemarthrosis can occur as a result of any injuries. Accumulation of blood in bruises of the knee joint, as a rule, is formed as a result of a fall or (less often) a direct blow. Hemarthrosis with ligament rupture and meniscus rupture often becomes a consequence of sports injury. Hemarthrosis in intraarticular fractures can occur both as a result of a normal fall on the knee, and as a result of larger accidents: traffic accidents or falls from a height. In case of serious accidents, a combination with other injuries is possible: chest injuries, fractures of the spine, pelvis and limb bones, TBI, blunt abdominal trauma and damage to the genitourinary system.
A more or less pronounced accumulation of blood is also characteristic of the postoperative period during various planned surgical interventions on the knee joint, for example, when removing the meniscus, stitching cruciate ligaments, osteosynthesis of the femoral condyles, osteosynthesis of the tibial condyles with plates or screws. With hemophilia, scurvy and bleeding diathesis, hemarthrosis can develop even after minimal trauma. In some cases, the traumatic effect is so insignificant that the patient cannot even remember it.
With the first degree of pathology (the volume of blood spilled up to 15 ml), the joint is slightly increased in volume. The symptoms of the underlying injury (usually a knee joint injury) prevail. The pain is local in the area of injury, there are no bursting pains in the joint. The support on the leg is free or somewhat limited. With the second degree of hemarthrosis (the volume of blood spilled up to 100 ml), the joint increases in volume, becomes spherical, its contours are smoothed.
During palpation, fluctuation is determined. With a significant accumulation of blood in the knee joint, there is a noticeable swelling along the anterolateral surfaces from the outside and inside of the patella. With continued bleeding and the third degree of hemarthrosis (the volume of blood spilled is more than 100 ml), the skin can become cyanotic, and soft tissues can become very tight, tense. In some cases, there is an increase in local temperature.
If the hemarthrosis is caused by a bruise or is of a non-traumatic nature (caused by hemophilia, scurvy, etc.), the patient complains of moderate bursting pains in the joint, especially pronounced when a large amount of blood is poured out. Foot support is possible, movements are somewhat limited. With hemarthrosis caused by more severe injuries (ligament rupture or meniscus rupture, fractures), symptoms characteristic of a particular injury are revealed. So, if the ligaments are damaged, instability of the joint will be observed, with a fracture, sharp soreness will occur, and support on the leg will be impossible, etc.
In the absence of timely treatment, a small amount of blood in the joint may resolve on its own. With severe hemarthrosis, the blood subsequently becomes more liquid, which causes the swelling in the joint area to “soften”. The joint seems to swell, the bulges on its side surfaces “slide” downwards when the body position changes. Along with this, the formation of clots is possible, which in some cases can be felt under the fingers when feeling.
Due to the accumulation of blood in the joint cavity, the tissues are compressed, their blood circulation is disrupted, which can become an impetus for the development of dystrophic changes (especially with repeated hemarthrosis). Subsequently, the blood cells begin to disintegrate, the decay products enter the tissues, and this also has a negative effect on the hyaline cartilage and the joint capsule. Hemosiderin accumulates in the tissues (a pigment formed during the destruction of blood cells), because of this, the capsule, cartilage and ligaments become less elastic. Small foci of destruction appear on the surface of the cartilage, the cartilage loses its integrity and becomes less smooth. This, in turn, causes further traumatization of the cartilaginous surfaces during movement, which over time can lead to the development of arthrosis.
In some cases, the breakdown products of blood cells cause inflammation of the synovial membrane of the joint. The shell begins to secrete an increased amount of inflammatory fluid, an effusion appears in the joint, aseptic synovitis develops. If pathogenic organisms enter the inflammatory fluid by hematogenic (through blood) or lymphogenic (through lymphatic vessels), synovitis can become infectious. When the process spreads to the fibrous membrane of the joint capsule and surrounding tissues, purulent arthritis may develop.
The diagnosis of hemarthrosis is made by an orthopedic traumatologist based on clinical data and medical history. In order to exclude bone damage, all patients with suspected hemarthrosis are referred for knee joint radiography. If necessary (for example, if ligament rupture or cartilage damage is suspected), other additional studies may be prescribed: CT or knee MRI, arthroscopy, etc. Suspicion of non-traumatic hemarthrosis is an indication for consultation with a hematologist.
If the corresponding symptoms appear, you should contact the emergency room as soon as possible in order to receive timely treatment and prevent the development of complications. At the prehospital stage, it is necessary to provide rest to the limb by placing it on a horizontal surface with a small pillow under the knee joint. You can apply cold to the joint (a hot water bottle with cold water or an ice bag wrapped in a towel).
At the first degree of hemarthrosis, a puncture is not performed, since such an amount of blood resolves independently. A plaster splint is applied to the leg, it is recommended to apply cold for 1-2 days, maintain the elevated position of the limb and limit the load. Subsequently, UHF is prescribed. The duration of immobilization depends on the underlying injury.
If the amount of blood in the joint exceeds 25-30 ml, a puncture is necessary. The puncture is performed under local anesthesia. First, a thin needle is inserted along the outer-lateral surface of the joint, just below the patella, to numb the soft tissues and capsule. Then the needle is changed to a special, thicker and longer one. The blood is removed, the joint cavity is washed with novocaine. If necessary, hydrocortisone or triamcinolone is administered.
Then a tight bandage is applied to the joint and immobilization is performed with a spar. Sometimes blood accumulates in the joint again, so after 1-2 days a second examination is prescribed. If necessary, the puncture is repeated. Usually 1-2, less often 3 punctures are enough. The elevated position of the limb and walking on crutches are recommended. The period of immobilization, as in the previous case, is determined by the main injury.
Hemarthrosis of the third degree, as a rule, accompanies severe injuries. In such cases, patients are hospitalized in the trauma department and the main injury is treated. Punctures are performed as blood accumulates in the joint. If third-degree hemarthrosis occurs in the absence of severe injuries, this is also a reason for hospitalization in the trauma department. Along with standard medical measures in such cases, a detailed examination is carried out: determination of blood clotting, MRI, CT, examinations by other specialists, etc.
Persistently recurrent hemarthrosis is also an indication for an in-depth examination, since repeated blood accumulations may be due to cartilage damage that is not visible on radiographs. Usually in such cases, the patient is referred for arthroscopy of the knee joint – this therapeutic and diagnostic method allows not only to clarify the cause of repeated bleeding, but also in some cases to carry out all the necessary therapeutic manipulations. For example, to remove damaged pieces of cartilage or a torn part of the meniscus.
Hemarthrosis in hemophilia, along with standard therapeutic measures, requires blood plasma transfusion and intravenous administration of antihemophilic globulin. Treatment is carried out in the hematology department.
Prognosis and prevention
The prognosis for traumatic hemarthrosis is usually favorable, especially in the case of timely treatment in a medical institution. Recurrent hemarthrosis, as well as hemarthrosis in severe injuries and hemophilia can cause complications and subsequent formation of knee arthrosis. Preventive measures include the prevention of injuries at home and at work, timely treatment of diseases that can cause hemarthrosis.
- Baker CL. Acute hemarthrosis of the knee. J Med Assoc Ga. 1992 Jun;81(6):301-5. – link
- Kawamura H, Ogata K, Miura H, Arizono T, Sugioka Y. Spontaneous hemarthrosis of the knee in the elderly: etiology and treatment. Arthroscopy. 1994 Apr;10(2):171-5. – link
- Worland RL, Jessup DE. Recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty. 1996 Dec;11(8):977-8.
- Manners PJ, Price P, Buurman D, Lewin B, Smith B, Cole CH. Joint Aspiration for Acute Hemarthrosis in Children Receiving Factor VIII Prophylaxis for Severe Hemophilia: 11-year Safety Data. J Rheumatol. 2015 May;42(5):885-90.
- Olsson O, Isacsson A, Englund M, Frobell RB. Epidemiology of intra- and peri-articular structural injuries in traumatic knee joint hemarthrosis – data from 1145 consecutive knees with subacute MRI. Osteoarthritis Cartilage. 2016 Nov;24(11):1890-1897. – link