What is the management of traumatic hemarthrosis (bleeding into a joint space)?

From the Guidelines

The management of traumatic hemarthrosis should prioritize immediate control of bleeding, followed by joint aspiration and stabilization, with the goal of reducing morbidity, mortality, and improving quality of life, as supported by the most recent guidelines from 2021 1.

Key Considerations

• The initial assessment of the patient's clinical status is crucial in determining the risk of perioperative complications and guiding the management approach.
• The use of a tourniquet may be necessary in cases of severe limb trauma with active bleeding, and its effectiveness, usefulness, and location should be re-evaluated as soon as possible to limit morbidity.
• In patients with severe limb trauma, the presence of one or more Vittel criteria in the prehospital setting should prompt admission to a specialized Trauma Centre.

Management Approach

• Prompt control of bleeding is essential to prevent further complications, and the use of a tourniquet or other hemostatic measures may be necessary.
• Joint aspiration may be necessary to relieve pressure and reduce pain, typically performed under sterile conditions using an 18-20 gauge needle.
• Pain management should include acetaminophen as first-line therapy, with NSAIDs or short-term opioids added if needed, while being cautious of bleeding risk.
• Physical therapy should begin as soon as tolerated to prevent stiffness and muscle atrophy, focusing initially on gentle range of motion exercises and progressing to strengthening.
• Underlying causes, such as ligament tears, meniscal injuries, or fractures, should be addressed, and orthopedic consultation may be necessary.

Special Considerations

• In patients with bleeding disorders, such as hemophilia, factor replacement therapy is essential before any invasive procedures.
• The goal of treatment is to reduce pain and swelling while preserving joint function and preventing long-term complications, such as arthropathy.

Guiding Principles

• The management approach should prioritize the patient's clinical status, the severity of the injury, and the risk of complications.
• The use of evidence-based guidelines, such as those from 2021 1 and 2013 1, should inform the management approach to ensure optimal outcomes.

From the Research

Management of Traumatic Hemarthrosis

The management of traumatic hemarthrosis, or bleeding into a joint space, is a complex process with various treatment options. Some of the key considerations include:

• The presence of blood in the joint can lead to degenerative changes and osteoarthritis, making prompt treatment essential 2
• There is no consensus on the optimal management of traumatic knee joint injury with hemarthrosis, but joint aspiration may be beneficial in minimizing the harmful effects of blood 2
• Arthroscopy and magnetic resonance imaging (MRI) are commonly used diagnostic tools, with arthroscopy allowing for both diagnostic and therapeutic procedures 3, 4

Diagnostic and Therapeutic Procedures

Some studies suggest that arthroscopic examination is necessary in patients with acute traumatic hemarthrosis of the knee, as it allows for the identification and treatment of underlying injuries such as:

• Anterior cruciate ligament (ACL) tears 4, 5
• Meniscal tears 4, 5
• Chondral or subchondral fractures 4
• Ligament sprains 5

Treatment Approaches

Treatment approaches for traumatic hemarthrosis may include:

• Arthroscopic therapeutic procedures, such as debridement or repair of damaged tissues 4
• Conservative management, including anti-inflammatory medications and physical therapy 6
• Selective embolization of geniculate arteries, which may be effective in managing recurrent spontaneous hemarthrosis 6