- Peter A Nigrovic, MD
Peter A Nigrovic, MD
- Associate Professor of Medicine
- Harvard Medical School
Bleeding into a joint is referred to as hemarthrosis and is an important cause of monoarticular joint pain and swelling. Hemarthrosis may be suspected on the basis of a suggestive history, physical examination, or imaging studies, but definitive diagnosis usually requires joint aspiration. (See "Evaluation of the adult with monoarthritis" and "Joint aspiration or injection in adults: Technique and indications" and "Joint aspiration or injection in children: Indications, technique, and complications".)
Synovial fluid obtained from a patient with a hemarthrosis may appear red, pink, or brown. Other abnormalities of the fluid may be noted that depend upon the cause of the bleeding. As an example, the presence of lipid globules strongly suggests an intraarticular fracture, resulting in leakage of marrow fat into the synovial fluid. A true bloody effusion usually fails to clot due to chronic fibrinolysis, while blood from a traumatic aspiration generally does coagulate .
If the aspiration is not bloody initially, but fresh blood appears after some synovial fluid has been withdrawn, the most likely cause is a traumatic arthrocentesis. In this case, centrifugation of the specimen is useful. A serous appearance of the synovial fluid supernatant suggests that fresh blood has been admixed with previously nonbloody fluid. The aspirate from a patient with hemarthrosis will generally exhibit xanthochromia from lysis of the resident erythrocytes.
Although diagnosis of hemarthrosis usually requires joint aspiration, arthrocentesis is generally not required for diagnosis when the underlying cause is known with confidence (eg, patients with hemophilia and a history of hemarthrosis), and when important alternate diagnoses such as septic arthritis can be excluded clinically.
CAUSES OF HEMARTHROSIS
Broad categories of disorders that may result in hemarthrosis include trauma, bleeding disorders, neurologic deficits, arthritis, neoplasms, vascular damage, and other miscellaneous causes (table 1).
- Dougados M. Synovial fluid cell analysis. Baillieres Clin Rheumatol 1996; 10:519.
- Baker CL. Acute hemarthrosis of the knee. J Med Assoc Ga 1992; 81:301.
- Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br 1993; 75:945.
- Visuri T, Koskenvuo M, Dahlström S. Hemarthrosis of the clinically stable knee due to sports and military training in young recruits: an arthroscopic analysis. Mil Med 1993; 158:378.
- Allum R. The management of acute traumatic haemarthrosis of the knee. Br J Hosp Med 1997; 58:138.
- Bomberg BC, McGinty JB. Acute hemarthrosis of the knee: indications for diagnostic arthroscopy. Arthroscopy 1990; 6:221.
- Ryu KN, Jaovisidha S, De Maeseneer M, et al. Evolving stages of lipohemarthrosis of the knee. Sequential magnetic resonance imaging findings in cadavers with clinical correlation. Invest Radiol 1997; 32:7.
- Lugo-Olivieri CH, Scott WW Jr, Zerhouni EA. Fluid-fluid levels in injured knees: do they always represent lipohemarthrosis? Radiology 1996; 198:499.
- Bianchi S, Zwass A, Abdelwahab IF, et al. Sonographic evaluation of lipohemarthrosis: clinical and in vitro study. J Ultrasound Med 1995; 14:279.
- Ames PR, Maffulli N, Capasso G, Brancaccio V. Minimal trauma knee hemarthrosis. Bull Hosp Jt Dis 1996; 54:258.
- Lu KH, Hsiao YM, Lin ZI. Arthroscopy for acute knee haemarthrosis in road traffic accident victims. Injury 1996; 27:341.
- Worland RL, Jessup DE. Recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty 1996; 11:977.
- Ballard WT, Clark CR, Callaghan JJ. Recurrent spontaneous hemarthrosis nine years after a total knee arthroplasty. A presentation with pigmented villonodular synovitis. J Bone Joint Surg Am 1993; 75:764.
- Oishi CS, Elliott ML, Colwell CW Jr. Recurrent hemarthrosis following a total knee arthroplasty. J Arthroplasty 1995; 10 Suppl:S56.
- Schneider T, Fink B, Abel R, et al. Hemarthrosis as a major complication after arthroscopic subcutaneous lateral retinacular release: a prospective study. Am J Knee Surg 1998; 11:95.
- Wild JH, Zvaifler NJ. Hemarthrosis associated with sodium warfarin therapy. Arthritis Rheum 1976; 19:98.
- Jaffer AM, Schmid FR. Hemarthrosis associated with sodium warfarin. J Rheumatol 1977; 4:215.
- Birnbaum Y, Stahl B, Rechavia E. Spontaneous hemarthrosis following thrombolytic therapy for acute myocardial infarction. Int J Cardiol 1993; 40:289.
- Finlayson J, Dunsmuir RA. Haemarthrosis following thrombolytic therapy for acute myocardial infarction. Injury 1997; 28:146.
- Lan HH, Eustace SJ, Dorfman D. Hemophilic arthropathy. Radiol Clin North Am 1996; 34:446.
- Arnold WD, Hilgartner MW. Hemophilic arthropathy. Current concepts of pathogenesis and management. J Bone Joint Surg Am 1977; 59:287.
- Roosendaal G, Vianen ME, Marx JJ, et al. Blood-induced joint damage: a human in vitro study. Arthritis Rheum 1999; 42:1025.
- Rodriguez-Merchan EC. The destructive capabilities of the synovium in the haemophilic joint. Haemophilia 1998; 4:506.
- Roosendaal G, Tekoppele JM, Vianen ME, et al. Articular cartilage is more susceptible to blood induced damage at young than at old age. J Rheumatol 2000; 27:1740.
- Wen FQ, Jabbar AA, Chen YX, et al. c-myc proto-oncogene expression in hemophilic synovitis: in vitro studies of the effects of iron and ceramide. Blood 2002; 100:912.
- Jansen NW, Roosendaal G, Bijlsma JW, et al. Exposure of human cartilage tissue to low concentrations of blood for a short period of time leads to prolonged cartilage damage: an in vitro study. Arthritis Rheum 2007; 56:199.
- Feldman BM. Preventing joint damage from hemophilia. J Rheumatol 2000; 27:1579.
- Kawamura H, Ogata K, Miura H, et al. Spontaneous hemarthrosis of the knee in the elderly: etiology and treatment. Arthroscopy 1994; 10:171.
- Braverman DL, Kern HB, Nagler W. Recurrent spontaneous hemarthrosis associated with reflex sympathetic dystrophy. Arch Phys Med Rehabil 1998; 79:339.
- Mowad CM, Howe KL, Guzzo CA. Unexplained hemothorax, hemarthrosis, and palpable purpura. Hosp Pract (Off Ed) 1995; 30:55.
- Klein GE, Raith J, Passler J, et al. Spontaneous recurrent hemarthrosis of the knee joint: endovascular treatment of a ruptured aneurysm with platinum microcoils. A case report. J Bone Joint Surg Am 1997; 79:594.
- Wirth T, Rauch G, Rüschoff J, Griss P. Synovial haemangioma of the knee joint. Int Orthop 1992; 16:130.
- Frassica FJ, Bhimani MA, McCarthy EF, Wenz J. Pigmented villonodular synovitis of the hip and knee. Am Fam Physician 1999; 60:1404.
- Kroot EJ, Kraan MC, Smeets TJ, et al. Tumour necrosis factor alpha blockade in treatment resistant pigmented villonodular synovitis. Ann Rheum Dis 2005; 64:497.
- Bragadóttir G, Onundarson PT. Factor-sparing use of the COX-2 inhibitor rofecoxib in haemophilic arthropathy. Haemophilia 2002; 8:832.
- Thumboo J, O'Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum 1998; 41:736.
- Son KM, Kim JK, Seo YI, Kim HA. A case of bilateral hemarthrosis due to pseudoaneurysms in a patient on anticoagulation therapy. J Clin Rheumatol 2013; 19:206.
- Katsimihas M, Robinson D, Thornton M, Langkamer VG. Therapeutic embolization of the genicular arteries for recurrent hemarthrosis after total knee arthroplasty. J Arthroplasty 2001; 16:935.
- Omary R, Stulberg SD, Vogelzang RL. Therapeutic embolization of false aneurysms of the superior medial genicular artery after operations on the knee. A report of two cases. J Bone Joint Surg Am 1991; 73:1257.
- JOINT ASPIRATION
- CAUSES OF HEMARTHROSIS
- - Knee injury
- - Lipohemarthrosis
- - Minimal injuries
- - Postoperative
- - Bleeding disorders
- - Osteoarthritis
- - Neurologic disorders
- - Septic arthritis
- - Vascular disorders
- - Tumors
- - After major trauma
- - Coagulopathy
- - Postoperative
- - Aneurysms
- - Benign tumors
- SUMMARY AND RECOMMENDATIONS