Joint Bleeds
"Target joints"
The hallmark of hemophilia is joint and muscle bleeding. Spontaneous joint and muscle bleeding can occur without a definite history of trauma. The patient may not be able to identify a specific event that resulted in bleeding.
While persons with hemophilia may bleed into any joint space, the joints which most frequently bleed are the elbows, knees, and ankles. Other possible bleeding joint sites include the shoulders and hips. As repeated bleeding occurs, the synovial tissue thickens and develops even more friable blood vessels. A vicious cycle of bleeding and rebleeding may set in and the affected joint is referred to as a "target joint." Eventually, repeated bleeding into joints leads to a form of chronic arthritis with destruction of cartilage and the eventual destruction of bone resulting in decreased joint mobility and function.
Signs and symptoms
Outward signs of joint bleeding include restriction of movement, swelling, heat, and erythema on and around the joint. The patient may report symptoms of a bubbling or tingling sensation with no physical signs. Later symptoms include a feeling of fullness within the joint and moderate to severe pain as the bleed worsens.
Treatment
Some patients may present for treatment with no other outward signs of bleeding than decreased range of motion and a complaint of pain or tingling. This is indicative of an early onset joint bleed and is the optimal time to treat. The patient should be infused as quickly as possible with a routine dose of factor in order to minimize pain and joint destruction. Extreme pain, swelling, heat, and immobility are signs and symptoms of an advanced joint bleed which occurs only after blood has filled the joint space. Symptoms suggestive of an advanced joint bleed require a major factor dose.
Infuse before any diagnostic procedures such as x-ray. If a joint bleed is treated early before obvious outward signs occur, then the need for expensive follow-up infusions may be lessened or avoided altogether. Before dislocated joints are reduced, infuse with a major factor dose.
Joint aspiration: Caution!
Joint bleeds in hemophilia are generally not treated by aspirating the joint. This procedure can make matters worse by creating another site from which the patient may bleed. If joint aspiration is deemed necessary, such as in suspected joint sepsis, then the joint should be aspirated by an orthopedic surgeon associated with a hemophilia treatment center. The patient's hematologist must be involved in order to arrange for factor coverage before and after the procedure.
Discharge and follow-up care
Upon discharge, the hemophilia patient with a joint bleed should be instructed to keep the affected joint at rest, elevate the affected limb, and apply ice packs. Additional support to the affected joint may be applied by wrapping with an ace bandage. For ankle bleeds, an Aircast may be a useful splinting device. Crutches are useful to help individuals when they have lower extremity joint bleeds and need to be non-weight bearing. Follow-up should be made to the local hemophilia treatment center or to the patient's hematologist as soon as possible.
Discharge Instructions
For the next 24 hours:
- RICE: Rest, Ice, Compression (ace bandage), Elevation
- sling or splinting if support is needed (i.e. Aircast for ankles)
Follow-up with the hemophilia treatment center or with the patient's hematologist.