Ultrasound in addition to clinical assessment of acute musculoskeletal complaints in bleeding disorders: impact on patient management

Abstract

Background: Ultrasound is increasingly used for musculoskeletal assessment in hemophilia care.

Objectives: To evaluate the impact of point-of-care ultrasound added to clinical assessment for diagnosis and treatment of acute musculoskeletal episodes in a heterogeneous cohort of children and adults with hemophilia and von Willebrand disease (VWD).

Methods: This prospective cross-sectional study consecutively included children and adults with hemophilia or VWD who visited the outpatient clinic with acute musculoskeletal complaints between March 2020 and May 2023. For all episodes, initial diagnosis and treatment determined by clinical assessment were recorded on a case report form. Subsequently, a physiotherapist (M.A.T. and J.B.) with knowledge of the clinical diagnosis performed point-of-care ultrasound. After ultrasound, updated diagnosis and treatment were recorded. Diagnosis and treatment before and after ultrasound were compared, and proportions of change with 95% CIs were determined.

Results: We evaluated 77 episodes in 67 patients (median age, 24 years; IQR, 13-42 years). Before ultrasound, 37 joint bleeds, 13 muscle bleeds, and 27 other diagnoses were diagnosed. After ultrasound, 33 joint bleeds, 11 muscle bleeds, and 33 other diagnoses were confirmed. The diagnosis changed in 28 of 77 episodes (36%; 95% CI, 26%-48%). Nine joint bleeds and 2 muscle bleeds were missed by clinical assessment. Ultrasound findings changed treatment strategy in 30 of 77 episodes (39%; 95% CI, 28%-51%).

Conclusion: Ultrasound in addition to clinical assessment of acute musculoskeletal complaints in people with hemophilia and VWD has an impact on diagnosis (36%) and treatment (39%), which supports the use of ultrasound in acute musculoskeletal complaints in hemophilia and VWD.

Keywords: hemarthrosis; hemophilia; physical examination; point-of-care testing; ultrasonography.

Figure 1

A flowchart summarizing the study design. VWD, von Willebrand disease.

Figure 2

Sankey diagram visualizing the change in diagnoses before and after ultrasound assessment. Ultrasound findings changed the diagnosis in 28 of 77 episodes (36%; 95% CI, 26%-48%).

Figure 3

Midsagittal ultrasound images of the tibiotalar joint from 2 example cases illustrating discrepancies between clinical impression and ultrasound findings. Case 1: a traumatic, painful episode of the left ankle (Hemophilia Joint Health Score, 1) in a 10-year-old boy with severe hemophilia A on prophylaxis suspected of ligament injury based on clinical impression. After ultrasound, the final diagnosis was joint bleeding. The patient presented with constant diffuse pressing pain on weight-bearing and active range of motion (AROM). Despite the pain, AROM and gait were normal. Pain decreased after clotting factor concentrate. The patient had no pain at rest or during sleep. The ankle was not swollen and had a normal color and temperature. (A) Ultrasound showed complex joint effusion. (B) Graphic representation of the anatomical bony landmarks (distal tibia and talus) and the complex effusion on the ultrasound image in panel A. Case 2: a traumatic, painful episode of the left ankle (Hemophilia Joint Health Score, 0) in a 15-year-old boy with moderate hemophilia A treated on demand, suspected of joint bleeding based on clinical impression. After ultrasound, the final diagnosis was ligament injury. The patient presented with localized stabbing pain on weight-bearing and AROM. AROM was limited, and gait was asymmetric. Pain decreased with motion and after clotting factor concentrate. The patient had no pain at rest or during sleep. The ankle was diffusely swollen with normal color and temperature. (C) Ultrasound showed no joint effusion. (D) Graphic representation of the anatomical bony landmarks (distal tibia and talus) on the ultrasound image in panel C.

Figure 4

Stacked bar chart visualizing changes in treatment plans after ultrasound assessment.