HEMARTHROSIS
Recurrent or chronic hemarthrosis is the most
common complication of a group of heritable disorders of blood coagulation (see Ch. 167).
Hemarthrosis can be a complication of anticoagulant therapy or severe trauma to a normal
joint. In hemophilia, joint bleeding usually begins before the age of five and tends to
recur repeatedly during childhood in response to even minor injury. The most common sites
are the knees, elbows, and ankles, but any joint can be involved.
Acute hemarthrosis usually results in marked
local inflammation and joint symptoms that can last for days to weeks. Approximately one
half of patients with hemophilia develop chronic deformities in one or more joints. Some
of them develop a chronic progressive synovitis, restricted to one or a few joints, which
clinically and roentgenographically resembles rheumatoid arthritis. In chronic cases there
is marked synovial membrane hyperplasia, destruction of articular cartilage, and erosions
of subchondral bone. This chronic pro- gressive pattern probably results from a low level
of continuous or intermittent bleeding into involved joints. joint fluid, in chronic
cases, usually contains blood and very high levels of leukocyte-derived proteases. Other
musculoskeletal manifestations of hemophilia include bleeding into muscle and bone * The
resolution of large hematomas can produce chronic cysts within these tissues.
Management of Hemarthrosis
The first principle in management is to
prevent trauma, a goal not easily achieved in children. Acute hemarthrosis should be
managed by immobilization, analgesic therapy, and the administration of appropriate plasma
concentrates that contain the required coagulation factor. Aspirin and other nonsteroidal
analgesics that alter platelet function should be avoided. If there is marked distention
of a joint or bursa, aspiration can be accomplished after the defect in coagulation has
been corrected. When pain and acute inflammation have subsided, an exercise program to
restore range of joint motion should be initiated. For the patient with severe chronic
deforming joint disease, the availability of potent plasma concentrates has made it
possible to perform synovectomy and arthroplasty in selected instances. |
