Hand

Question 1

Hand schpiel:

Answer 1

Today I examined ____.

He/she had evidence of a symmetrical/asymmetrical, deforming/non-deforming arthropathy involving x joints.

There was evidence/no evidence of disease activity and sparing/involvement of the DIPJ’s.

Extra-articular features included ____.

This leads me to a diagnosis of ____ but there are other differentials.

My findings in more detail are ____.

Question 2

RA signs

Answer 2

• Ulnar deviation MCP/wrist
• Swan neck deformity
• Boutonnier’s deformity
• Z-deformity

Question 3

OA signs

Answer 3

• Heberden’s nodes
• Bouchard’s nodes
• Squaring of the MCP joints

Question 4

Psoriatic arthritis signs

Answer 4

• Sausage digits/dactylitis

Question 5

Cases

Answer 5

• RA (29%)
• Limited Scleroderma/Scleroderma (19%)
• Psoriatic Arthropathy (10%)
• Ankylosing Spondlyitis (8%)
• Gout (3%)
• Haemochromotosis/SLE (2%)

Question 6

Extra articular manifestations of RA:

Answer 6

• face (anaemia, dentition, eyes)
• chest (fibrosis, pleural effusions)
• heart (PHT, MR, AR)
• abdomen (splenomegaly, injection sites)
• pydoderma gangrenosusm

Question 7

Seronegative arthropathy signs:

Answer 7

• face (anaemia)
• abdomen (stoma)
• spine (axial disease)

Question 8

Gout areas:

Answer 8

• elbows & ears (tophi)
• other joints
• ? underlying cause

Question 9

Scleroderma steps:

Answer 9

• diffuse vs limited
• blood pressure
• face (alopecia, anaemia, bird-life facies, oral diameter, telangiectasia)
• abdomen (hepatosplenomegaly)
• chest:
• skin
• pulmonary fibrosis
• signs of Pul HTN
• cardiac failure

Question 10

Dermatomyositis

Answer 10

• Gottren’s sign (hands
• Mechanic hands
• Heliotrope rash (eyelids)
• Shawl sign (back and shoulders)
• Neuro upper and lower limb (power)
• Respiratory exam

Question 11

Causes of deforming polyarthopathy (6):

Answer 11

• RA
• SLE
• Gout
• OA
• PsA
• Scleroderma

Question 12

DIP involved (4):

Answer 12

• Gout
• PsA
• OA
• Scleroderma

Question 13

DIP not involved (2):

Answer 13

• RA

- SLE

Question 14

Where are Psoriatic plaques:

Answer 14

• Scalp
• Ears
• Elbows
• Umbilicus
• Genitalia
• Gluteal cleft
• Knees
• Finger nails and toe nails

Question 15

Hand X-rays

Answer 15

• D emographics & DIPs
• S - oft tissue
• A - lignment
• B - one mineralisation & production
• C - artilage (joint space) & calcification
• D - istribution
• E - rosions

Question 16

RA main findings on XR

Answer 16

• soft tissue swelling (swelling fusiform)
• juxta-articular osteopenia (becomes more generalised as the disease progresses
• initial joint space widening secondary to effusions; then become narrowed (concentric rather then eccentric)
• erosions initially at areas not covered by cartilage (intracapsular articular margins), then marginal erosions

Question 17

PsA main findings on XR

Answer 17

• asymmetric destruction of the DIPs with bony ankylosis
• no or minimal juxta-articular osteopenia
• bone proliferation near joints and ligaments or tendon insertion sites (enthesis)
• bone erosions beginning in the periarticular region and progressing to more central areas
• soft tissue swelling (dactylitis)
• resorption of the terminal phalangeal tufts
• osteolysis of the bone with telescoping of the digit

Question 18

Gout main findings on XR

Answer 18

• asymmetric soft tissue swelling
• juxta-articular erosions with sclerotic margin
• rat-bite appearance to erosions

Question 19

Reporting back (hand):

Answer 19

• Intro - make the call, active vs non active, cx of disease, rx
• Look
• Feel
• Move
• Extra-articular
• Summary
• Relevant investigations (with likely results; straight forward stuff first)
• Keep talking!

Question 20

RA extra-articular manifestations:

Answer 20

• MSK: examine other joints (shoulder, elbows, knees and feet).
• Cervical spine: atlantoaxial subluxation (cervical myelopathy).
• Eyes: episcleritis, scleritis, Sjogren’s
• Anaemia: conjunctival pallor
• Lungs: pleural effusion, pulmonary fibrosis, Caplan’s syndrome, bronchiectasis
• Heart: pericarditis, VHD
• Skin: pyoderma gangrenosum
• Abdomen: splenomegaly (Felty’s syndrome), hepato-splenomegaly (secondary amyloidosis)
• Kidney’s: nephrotic syndrome (oedema and proteinurina)
• Nervous system: mononeuritis multiplex, polyneuropathy

Question 21

Causes for anaemia in RA

Answer 21

• Anaemia of chronic disease
• Fe-deficiency (GI loss secondary to NSAIDs)
• Folate deficiency secondary to MTx
• Pernicious anaemia (associated with AI disease)
• BM suppression (gold, sulphasalazine, MTX and penicillamine)
• Felty’s syndrome
• AI haemolytic anaemia
• Anaemia of renal disease

Question 22

Organ systems involved in Scleroderma:

Answer 22

• Skin: RP, sclerodactyly; soft tissue atrophy, calcinosis, nail dystrophy, ulceration, grangrene, flexion deformities, oedema, telangiectasia, vitiligo, morphoea, pigmentation and pruritis.
• MSK: arthritis, myositis, myopathy, intra-articular calcification, osteopenia.
• GI: dysphagia, GORD, intestinal hypomotility –> bacterial overgrowth –> steatorrhoea and malabsorption, pneumatosis coli, colonic diverticulae, bowel obstruction, PBC.
• Renal: malignant HTN, GN, renal crises.
• Respiratory: ILD, restrictive lung defects, pleural effusions, atelectasis.
• CV: restrictive CM (myocardial fibrosis), pericarditis, pericardial effusions, pulmonary HTN, conduction defects.

Question 23

Diagnostic criteria for scleroderma:

Answer 23

• Major: skin sclerosis affecting arms, face and/or neck
• Minor: sclerodactyly, flinger pulp atrophy, bilateral pulmonary fibrosis.

1 MAJOR or 2 MINOR criteria are required to make a diagnosis.

Question 24

Nerve function in hands (3)

Answer 24

• Thumb up - median
• Finger abduction - ulnar
• Wrist extension - radial

Question 25

DDx back exam (5)

Answer 25

• Ank Spond
• PsA with axial involvement
• Enteropathic - IBD-stoma
• Reactive
• DISH - diffuse idiopathic skeletal hyperostosis
• OA