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Haemarthrosis – Joint Bleeding: Causes and Treatment

Haemarthrosis refers to bleeding into a joint space. It commonly occurs after injuries or in patients with bleeding disorders, causing swelling, pain, and restricted movement.

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Things worth knowing about "Haemarthrosis"

Haemarthrosis refers to bleeding into a joint space. It commonly occurs after injuries or in patients with bleeding disorders, causing swelling, pain, and restricted movement.

What is Haemarthrosis?

Haemarthrosis (also spelled hemarthrosis) is the accumulation of blood within a joint cavity or joint space. The blood originates from damaged or diseased blood vessels within or around the joint. The knee joint is most commonly affected, but the ankle, elbow, and shoulder joints can also be involved. Haemarthrosis is a serious condition because untreated blood within the joint can cause lasting damage to the cartilage and synovial membrane (the inner lining of the joint).

Causes

Haemarthrosis can result from a variety of causes:

Traumatic injuries: Sports injuries, falls, or accidents leading to ligament tears (e.g., anterior cruciate ligament rupture), meniscus damage, or intra-articular fractures are among the most common causes.
Bleeding disorders: Conditions such as haemophilia (a hereditary clotting disorder) prevent normal clotting, allowing joint bleeds to occur spontaneously or with minimal trauma.
Anticoagulant medications: Blood-thinning drugs (e.g., warfarin, direct oral anticoagulants) increase the risk of bleeding into joints.
Inflammatory joint conditions: Diseases such as rheumatoid arthritis or pigmented villonodular synovitis (PVNS) can cause abnormal blood vessel growth in the synovium, leading to recurrent joint bleeding.
Post-surgical or post-procedural bleeding: Joint replacement surgery or other orthopaedic procedures can occasionally lead to haemarthrosis.

Symptoms

The typical signs and symptoms of haemarthrosis include:

Rapid swelling of the affected joint, often developing within minutes to hours of the triggering event
Pain both at rest and during movement
Warmth and redness of the skin overlying the joint
Restricted range of motion of the joint
A feeling of tightness or pressure within the joint due to increased intra-articular pressure

In patients with haemophilia, these symptoms may develop without any obvious injury (so-called spontaneous bleeds).

Diagnosis

The diagnosis of haemarthrosis is established through:

Physical examination: The clinician assesses swelling, warmth, tenderness, and range of motion of the affected joint.
Joint aspiration (arthrocentesis): A fine needle is used to withdraw fluid from the joint. Bloody or blood-stained fluid confirms the diagnosis of haemarthrosis.
Imaging: Ultrasound can rapidly detect fluid within the joint, while MRI (magnetic resonance imaging) provides detailed information about associated injuries such as ligament or meniscus tears.
Blood tests: If a bleeding disorder is suspected, coagulation tests (e.g., aPTT, INR/prothrombin time, factor assays) are performed.

Treatment

Treatment depends on the underlying cause and the severity of the haemarthrosis:

Conservative Management

RICE protocol: Rest, Ice, Compression, and Elevation help to reduce swelling and pain in the acute phase.
Pain relief: Analgesics such as paracetamol or, where appropriate, non-steroidal anti-inflammatory drugs (NSAIDs) may be used.
Joint aspiration: Draining the blood from the joint relieves pressure, reduces pain, and helps prevent cartilage damage caused by blood enzymes.

Treatment of the Underlying Condition

In haemophilia, intravenous infusion of the missing clotting factor (e.g., Factor VIII or Factor IX) is the cornerstone of treatment to stop the bleed.
If anticoagulant medication is the cause, dose adjustment or reversal agents may be required under medical supervision.

Surgical Treatment

When haemarthrosis is associated with structural injuries such as an ACL rupture or meniscal tear, arthroscopic surgery or open surgical repair may be necessary.
For recurrent haemarthrosis caused by PVNS, surgical or arthroscopic synovectomy (removal of the affected synovial tissue) may be recommended.

Prognosis and Long-Term Outlook

With prompt and appropriate treatment, haemarthrosis generally resolves well. However, if blood is left untreated within the joint, iron deposits from the breakdown of haemoglobin (a process called haemosiderosis) can damage the cartilage and synovium, leading to progressive joint destruction known as haemophilic arthropathy. This is a major concern in patients with haemophilia who experience repeated joint bleeds over time. Early intervention and regular prophylactic treatment in haemophilia patients are therefore essential to preserving joint function.

References

Rodriguez-Merchan, E.C. - Haemophilic Synovitis: Aetiology, Diagnosis, Prognosis and Treatment. In: Haemophilia (2007), 13 Suppl 3, pp. 26-28.
Stiell, I.G. et al. - Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries. In: Journal of the American Medical Association (1996), 275(8), pp. 611-615.
World Federation of Hemophilia (WFH) - Guidelines for the Management of Hemophilia, 3rd Edition (2020). Available at: www.wfh.org

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