A joint that has recurring hemarthrosis (bleeding episodes) is known as a target joint, which typically means that around four separate bleeds have occurred in the same joint over a 6-month period. However, a target joint can also be caused by one severe bleed.
The most common joints affected are the knees, ankles, and elbows, although it can also occur in the hip, shoulders, and wrists.
What is hemarthrosis?
Hemarthrosis is a bleeding into a joint cavity and is a common complication of hemophilia.
Joint bleeding is a common complication of hemophilia — a genetic disorder that occurs when a clotting protein known as factor VIII or IX is defective or missing.
Over extended periods, excess bleeding can cause permanent damage in a person's joint, leading to reduced movement and sometimes, permanent disability.
The severity and frequency of the bleeds will determine how likely a person is to develop permanent damage.
Sometimes, a bleed into the joint space and the pressure caused by the blood filling the space can lead to severe pain, swelling, and deformity.
The damage caused by joint bleeding is similar to that of arthritis.
When bleeding occurs in the joint, it affects the cartilage that surrounds the bone. Cartilage prevents two bones that connect within a joint rubbing against each other when they move.
Joint bleeding destroys the cartilage, which erodes and becomes pitted. The damaged cartilage can no longer protect the bones from friction, so that they rub together, which is very painful. Over time, this will cause restricted movement in a person's joint.
The early signs that someone has a joint bleed leading to hemarthrosis include:
- warmth in the joint
- swelling in the joint
- tingling in the joint
- a baby with a bleeding joint may be irritable or crying for no reason that the parent can determine
Over time symptoms can become more serious and include:
- the skin over the joint feels warm
- loss of motion
- small children may refuse to straighten, use, or put weight on the affected limb
Physical therapy may be suggested as an alternative to surgery.
The treatment for hemarthrosis depends on the underlying cause of the joint damage and also how severe the damage is.
If another medical condition is causing the problem, then a doctor will need to diagnose and treat that separately.
Doctors can treat hemarthrosis, the pain, and the lack of movement associated with joint damage, with surgery.
If a person has hemophilia, they must discuss all surgery options thoroughly with a specialist blood doctor (hematologist) before they undergo any surgery.
However, most people with hemophilia take factor replacement therapy — a medication to replace the defective or missing clotting protein — which should prevent the hemarthrosis from happening in the first place.
There are two main types of surgery for treating hemarthrosis.
This procedure involves the removal of the synovium, which is the lining of a joint. The synovium helps lubricate the joint and also helps to remove any fluid and debris from the joint.
The synovium also contains blood vessels, which are the primary cause of any bleeding. Removing this lining stops the bleeding cycles.
A synovectomy will not make the joint 100 percent better, but it will help alleviate pain and improve movement.
There are three types of synovectomy:
- Radioactive: A doctor injects a radioactive fluid into the joint.
- Arthroscopic: A surgeon makes small incisions in the joint and removes the synovium, using a small camera for accuracy.
- Open: Full surgery involves opening the joint completely to remove the synovium.
Surgeons usually only carry out joint replacement surgery on people who have chronic, long-term pain that affects their daily life. During this procedure, a surgeon completely removes the damaged joint and bone and replaces them with plastic and metal components.
Surgeons carry out this procedure more often on people with knee and hip joint problems. After surgery and physiotherapy, a person who has had a joint replacement should feel no pain and experience improved movement.
90 percent of joint replacements last for 10 years.
Other types of surgery as treatment for joint pain include:
- Cheilectomy: Removal of small bony growths on the joint.
- Arthrodesis: Fusion of the joint.
- Osteotomy: Removal of a piece of bone in the leg to straighten it and reduce pain.
As an alternative to surgery, or after surgery for hemarthrosis, a person will need to undergo physical therapy.
There are several reasons for this:
- to reduce inflammation and pain
- to increase the range of motion and strengthen muscles around the joint
- to improve overall function
- to learn how to avoid painful movement.
There are also some lifestyle changes that individuals can make themselves to try and prevent and help alleviate symptoms of hemarthrosis:
- doing exercises that protect the joints and strengthen the muscles.
- losing weight if overweight
- avoiding activities that could cause a bleed
Taking anticoagulant tablets may be a cause of hemarthrosis.
Hemarthrosis is common in people who have bleeding disorders, such as hemophilia.
The National Hemophilia Foundation estimate that around 1 in every 5,000 babies is born with hemophilia in the United States. Currently, there are about 20,000 people in the US who have the condition.
Many older people who currently have hemophilia may already have or are at higher risk of developing hemarthrosis.
This is likely because when they were children, treatment was less advanced. In contrast, many children born with hemophilia today grow up with healthy joints, because they take factor replacement therapy to help their blood clot.
However, many other causes can lead to hemarthrosis:
- trauma caused by a sprain or injury
- blood-thinning drugs, known as anticoagulants
- infection in the joint
- some types of arthritis, such as osteoarthritis and hemophilic arthritis
- some types of cancer, commonly leukemia
Hemarthrosis in the knee is often caused by trauma, with ligament injuries, tears, fractures, and dislocations among the causes.
Hemarthrosis in the elbows is usually caused by impact trauma, which may occur during sports, such as diving.
When to see a doctor
If someone has any concerns about a bleed on the joint, then they should see a doctor as soon as they can, as the earlier the condition is treated, the better the outcome.
If the bleeding is not stopped, then it will eventually lead to permanent damage.
A person may have no visible symptoms to start with, so they may have to rely on what they feel rather than what they see. Anyone who has any concerns should contact their doctor.