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Hemarthrosis

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Definition

Hemarthrosis can be defined as the hemorrhage inside the joints, leading to other symptoms such as joint pain and inflammation. In making the diagnosis of hemarthrosis, the doctor will take into consideration the medical history of the patient and the results of the physical examination. The confirmation of the diagnosis is made after performing the procedure known as joint aspiration.

Hemarthrosis Symptoms

These are the most common symptoms of hemarthrosis:

  • Inflammation around the affected joint
  • Pain or tenderness upon palpation
  • Depending on the severity of the inflammation and the amount of intra-articular bleeding, the area can also appear red and warm to the touch
  • Tingling sensation can also be present
  • Repeated episodes of intra-articular bleeding can lead to symptoms such as chronic pain and inflammation
  • Difficult movement or reduced range of motion in the affected joint
  • Excessive bruising in the area corresponding to the affected joint
  • Broken blood vessels around the joint

Causes

These are the most common causes that lead to the appearance of hemarthrosis:

  • Trauma or injury
    • Sprain
    • Trauma or injuries of the extremities, affecting the major joints
  • Predisposition to hemorrhage
    • Medication – anticoagulants such as warfarin
    • Hemophilia – hereditary condition, in which the blood clotting mechanisms are impaired
  • Knee joint arthroplasty
  • Infection
    • Leptospirosis – infectious disease caused by spirochetes (genus Leptospira)
    • Clutton joint – symmetrical inflammation of the joints, encountered in patients who have been diagnosed with congenital syphilis
  • Hemorrhagic syndrome
    • Crimean-Congo hemorrhagic fever
      • Viral etiology
      • Tick-borne condition
      • Endemic in parts of Africa, Middle East, Asia and Europe (Balkan region)
  • Neurologic deficits
  • Osteoarthritis / hemophilic arthritis
    • Degenerative joint disease
    • Both the bone and the cartilage are affected by the degenerative changes
    • Joint pain and stiffness are common symptoms of this condition, apart from the hemarthrosis
  • Cancer – neoplastic growths
    • Acute leukemia – bone marrow cancer
    • Chondrosarcoma – cancer of the cells that constitute the joint cartilage
    • Synovioma – malignant or benign cancer, involving the tendon sheath
  • Vascular damage
  • At the level of the knees
    • Traumatic
      • Ligament injury – anterior or posterior cruciate ligament
      • Fracture (chondral, intra-articular)
      • Patella dislocation or fracture
      • Tear of the meniscus
      • Joint capsule tear (deep portion)
    • Non-traumatic
      • Pigmented villonodular synovitis – joint disease, caused by the excess growth of the synovial membrane (leading to inflammation, pain and hemarthrosis)
      • Synovial hemangioma – rare and benign vascular malformation, affecting the synovial membrane lining the inside of the joints
  • Other causes
      • Anemia (sickle cell)
      • Charcot neuropathic joint – loss of sensation in the joints, commonly encountered in patients who suffer from diabetes
      • Myeloproliferative disease (associated thrombocytosis) – diseases of the bone marrow
      • Hemorrhagic thrombocytopenia
      • Vitamin deficiency
      • Ruptured aneurysm (popliteal)
      • Arteriovenous fistula – abnormal connection formed between a vein and an artery
      • Factor X deficiency – inherited bleeding disorder, characterized by a defect in the factor X gene
      • Factor VII deficiency inherited bleeding disorder, characterized by a defect in the factor VII gene
      • Von Willebrand’s disease – genetic condition, characterized by coagulation abnormalities
      • Bleeding diathesis – unusual susceptibility to bleeding.

Treatment

The treatment of hemarthrosis depends first of all on the underlying cause that has contributed to the appearance of such problems. Below, you will find the most common treatments recommended for hemarthrosis:

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Synovectomy

  • Removal of the interior lining of the joint (synovial membrane)
  • Classic approach or through arthroscopy
  • Arthroscopy – minimally-invasive procedure, better recovery and faster healing, reduced risk of complications

Meniscectomy

  • Keyhole surgery
  • Partial or complete removal of the meniscus (protective cartilage of the tibio-femoral)
  • The partial removal means that the frayed edges of the meniscus might be trimmed or the meniscal rim will be removed
  • The complete removal refers to the fact that the entire meniscus is going to be removed, along with the meniscal rim
  • Arthroscopic approach for less severe cases (minimally-invasive, reduced stay in the hospital)

Osteotomy

  • Removal of bone wedge in the area of the affected joint, with the purpose of redirecting the weight away from the area that has been damaged
  • The procedure can bring the necessary pain relief in patients who suffer from hemarthrosis, improving the overall mobility in the affected joint
  • Most commonly performed at the hip or the knee joint
  • Requires a longer period of rehabilitation

Ablation

  • This procedure is performed with the purpose of debriding any diseased tissue that might be causing the intra-articular bleeding
  • Often recommended as a procedure in those who suffer from sacroiliac joint pain, with associated hemarthrosis

Joint replacement

  • In several cases, the surgeon will decide to perform partial or complete replacement of the joint
  • The joint is going to be replaced with an artificial prosthetic device

Mild cases

  • Depending on the joint – crutches or sling (protection of the damaged articulation) + rest

Hemarthrosis in hemophilic patients

  • Clotting agents – intravenous administration
    • Clotting factor VIII (for hemophilia A)
    • Clotting factor IX (for hemophilia B)
    • Recombinant clotting factors
  • Replacement therapy – prevent excess bleeding
  • Gene therapy

Physical therapy

  • In the first phase – useful to reduce the inflammation and pain
  • Other objectives – increase the range of motion in the affected joint, strengthening of the muscles surrounding the joint
  • Prevents contractures from developing
  • Improve the overall functioning, which is necessary for the daily living activities
  • The physical therapist can also teach you which are the movements that should be avoided, so as to reduce the pressure and physical stress on the affected joint

Complications

These are the complications that can occur in patients with hemarthrosis:

Cartilage damage

  • Encountered in those who suffer from different injuries (knee ligaments, capsule)
  • Depending on how extensive the damage is, in time, one can suffer from arthritis (progressive and degenerative condition).

In conclusion, this is a condition that can be successfully managed by treating the underlying disease. Physical therapy remains a valuable help for patients who are suffering from chronic clotting disorders, such as hemophilia.


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