Hemarthrosis
Definition
Hemarthrosis = bleeding into joint cavity
เป็นสาเหตุสำคัญของ:
- acute
monoarthritis
- painful
swollen joint
Definitive diagnosis:
arthrocentesis
Causes of Hemarthrosis
แบ่งเป็น:
- traumatic
- nontraumatic
1. Traumatic Hemarthrosis
สาเหตุพบบ่อยที่สุด
Clinical clue
- swelling
within hours after injury
- severe
pain
- rapid
effusion (<12 hr)
Rapid swelling →
suspect:
- ligament
injury
- osteochondral
fracture
- intraarticular
fracture
Knee Hemarthrosis (high-yield)
Most common mechanism:
- twisting
injury on loaded knee
Common associated injuries
|
Injury |
Approximate frequency |
|
ACL tear |
~70% |
|
Meniscal tear |
~10% |
|
Patellar subluxation/dislocation |
10–15% |
|
Osteochondral fracture |
2–5% |
Physical examination
ตรวจ:
- joint
line tenderness
- patella
tenderness
- ligament
stability
Tests:
- valgus/varus
- anterior
drawer/Lachman
- posterior
drawer
Imaging
Initial
- plain
radiograph
Knee views:
- AP
- lateral
- patellar
- tunnel
CT
ใช้เมื่อ:
- fracture
suspected but X-ray negative
MRI
ดีที่สุดสำหรับ:
- ligament
- meniscus
- cartilage
Lipohemarthrosis
Definition
fat + blood in joint
Suggests:
intraarticular fracture
Diagnosis
- arthrocentesis
- CT/MRI
- X-ray
fluid-fluid level
Double fluid-fluid level →
more specific
Hemarthrosis after Minimal Trauma
ให้คิดถึง:
- hemophilia
- coagulation
disorder
- acquired
factor inhibitor
ถ้าไม่มี bleeding disorder:
- ACL
tear
- meniscal
tear ยังเป็นไปได้
Postoperative Hemarthrosis
พบได้หลัง:
- TKA
- arthroscopy
Cause พบบ่อย:
- hypertrophic
synovium impingement
Treatment:
- synovectomy
- embolization
2. Nontraumatic Hemarthrosis
Important causes:
- bleeding
disorders
- anticoagulants
- OA/chondrocalcinosis
- neuropathic
joint
- septic
arthritis
- vascular
lesions
- tumors
Bleeding Disorders
Important labs
- CBC
- PT
- aPTT
Hemarthrosis มักเกิดจาก:
coagulation factor defect มากกว่า platelet
disorder
Hemophilia
Most common musculoskeletal manifestation:
hemarthrosis
Common joints
- knee
- elbow
- ankle
- hip
- shoulder
Types of Hemophilic Hemarthrosis
Acute
- painful
- swollen
- warm
- ↓ ROM
Older patients may report:
- “aura”
- tingling/warmth
before swelling
Subacute
- synovial
hypertrophy
- fibrosis
- reduced
ROM
Pain may not be prominent
Chronic
→
hemophilic arthropathy
Features:
- chronic
pain
- stiffness
- deformity
- OA-like
symptoms
Pathophysiology of Hemophilic Arthropathy
Blood in joint causes:
- synovial
proliferation
- cartilage
toxicity
- osteoclast
activation
- recurrent
bleeding (“target joints”)
Important:
blood can damage cartilage within ~2 days
Hemophilic Arthropathy Radiographic Stages
|
Stage |
Finding |
|
1 |
soft tissue swelling |
|
2 |
osteoporosis |
|
3 |
osseous deformity |
|
4 |
cartilage destruction |
|
5 |
joint disorganization |
MRI sensitive กว่า X-ray มาก
Osteoarthritis-related Hemarthrosis
Rare
Usually diagnosis of exclusion
Associated with:
- degenerative
meniscal tear
- chondrocalcinosis
Septic Arthritis
Rarely causes hemarthrosis
Always exclude if:
- fever
- systemic
symptoms
- inflammatory
synovial fluid
Vascular Causes
- aneurysm
- pseudoaneurysm
- vitamin
C deficiency
May require:
- surgery
- embolization
Tumor-associated Hemarthrosis
Important benign tumors:
Synovial hemangioma
- recurrent
painful monoarthritis
- usually
knee
- MRI
best diagnostic tool
TGCT/PVNS
(tenosynovial giant cell tumor / pigmented villonodular
synovitis)
Features:
- recurrent
hemarthrosis
- chronic
swollen joint
- locking/catching
- dark
brown aspirate
MRI:
- hemosiderin
→ dark on T1/T2
Treatment:
- synovectomy
Clinical Manifestations
Depends on acuity
Common findings:
- pain
- swelling
- warmth
- stiffness
- ↓ ROM
Synovial Fluid Findings
Appearance
- red
- pink
- brown/rusty
Important clues
True hemarthrosis
- usually
does NOT clot
- xanthochromia
after centrifuge
Traumatic tap
- blood
increases during aspiration
- straw-colored
supernatant
- usually
clots
Diagnosis
Gold standard
Arthrocentesis
Typical findings:
- uniformly
bloody fluid
- xanthochromia
When aspiration may not be necessary
- known
hemophilia
- known
traumatic intraarticular injury
- septic
arthritis unlikely
Additional synovial studies
ถ้า diagnostic uncertainty:
- cell
count
- differential
- Gram
stain
- culture
- crystal
analysis
- cytology
(if malignancy suspected)
Differential Diagnosis
1. Traumatic tap
Key distinction:
- fresh
clotting blood
- no
xanthochromia
2. Septic arthritis
Suggestive features:
- fever
- inflammatory
synovial fluid
- positive
culture
3. Crystal arthritis
- gout
- CPPD
Diagnosed by crystals
CPPD occasionally causes pseudo-hemarthrosis
4. Reactive arthritis
History:
- antecedent
infection
5. Lyme arthritis
- endemic
exposure
- large
knee effusion
Treatment
General Acute Management
Initial
- immobilization
- ice
- compression
Aspiration
Indications:
- tense
effusion
- pain
relief
- diagnostic
uncertainty
Use large-bore needle (eg 18G)
Analgesia
Avoid:
- nonselective
NSAIDs first 48–72 hr
COX-2 selective safer initially
Postacute
NSAIDs may be used after bleeding risk decreases
Important concept
Single episode hemarthrosis:
usually does not require lavage
Trauma-associated Hemarthrosis
- immobilize
- orthopedic
consultation
- assess
fracture/internal derangement
Hemophilia-associated Hemarthrosis
Requires:
- factor
replacement
- aggressive
treatment to prevent arthropathy
Children especially vulnerable
Anticoagulation-associated Hemarthrosis
Usually managed with:
- immobilization
- analgesia
Consider:
- anticoagulation
reversal if severe
Persistent/recurrent bleeding:
search for structural lesion
Postoperative Hemarthrosis
May require:
- revision
surgery
- embolization
Tumor-associated Hemarthrosis
Treatment:
- arthroscopic/surgical
synovectomy
Prognosis
Depends on cause
Important:
recurrent hemarthrosis in hemophilia → chronic disabling arthropathy
High-yield Clinical Pearls
- Acute
knee hemarthrosis after twisting injury →
ACL tear until proven otherwise
- Rapid
swelling within hours after trauma strongly suggests intraarticular injury
- Lipohemarthrosis
= think intraarticular fracture
- Minimal
trauma + hemarthrosis →
evaluate coagulopathy
- True
hemarthrosis usually does not clot
- Xanthochromia
supports true hemarthrosis
- Hemophilic
“aura” (tingling/warmth) is classic
- Recurrent
monoarticular bloody effusion →
think PVNS/TGCT or synovial hemangioma
- Bloody
joint fluid does NOT exclude septic arthritis
- Repeated
hemarthrosis destroys cartilage and leads to chronic arthropathy
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