Hand examination/arthritis and deformities Flashcards
1
Q
What is articular cartilage made of
A
- articular chondrocytes which provide
- extracellular matrix
2
Q
what is the extracellular matrix composed of
A
- collagen (type 2 forms fibrils that provide shear strength to matrix)
- proteoglycans, carry GAGs-chondroitin sulfate (bind with water molecules)
3
Q
Articular cartilage properties/function
A
- absorb compressive loads and deforms without damage (80% water- GAGs)
- withstand tensile shear stress (extracellular matrix) - collagen fibrils
- lubricates joint
- avascular = not good healing properties
- aneural = dont feel damage until its bone on bone
4
Q
Osteoarthritis DJD etiology
A
- Wear/tear - degradation of articular cartilage: natural occurrence of aging >40 y/o
- abuse, overuse
- joint injury
- hypermobility
- hypomobility
- post surgery
- heredity
- obesity especially in LE
5
Q
Explain how these can cause OA
1. joint injury
2. hypermobility
3. hypomobility
A
- intra-articular fx, dislocation, ligament tear can cause damage to articular cartilage as well
- hypermobility: excessive motion can cause wear and tear
- hypomobility: tight and doesn’t move = no nutrition getting to the joint
6
Q
How does OA cycle occur
A
- depletion of ground substance GAGS, chondroitin sulfate decreases, decreases in water content
- chondrocytes turn off and matrix therefore does not replace and collagen fibers fibrillate
- chondrocyte death occurs; release of proteolytic enzymes
- inflammation and activaiton of pain receptors
- capsillar fibrosis = decrease ROM, nutrition, lubrication
- progressive cartilage degradation, decrease shock/load absorption
- increase force to subchondral bone causing osteophytes
- altered joint mechanics
7
Q
Signs and symptoms of OA
A
- joint pain
- effusion
- stiffness
- crepitus
- muscule inhibition: decrease strength
- joint mobility: hypomobile (OA)
- abnormal movement patterns and compensations
8
Q
signs and symptoms in RA that differ from OA slightly
A
- hypermobile/instable
- deformities and altered joint mechanics
*can happen with OA but more common in RA
9
Q
POC for OA patients
A
- educate patient: activity modification, joint protection
- decrease joint stiffness: PROM, AAROM, AROM, joint mobilization(- increase ROM)
- Decrease mechanical stress and prevent deforming forces: prevent faulty mechanics, splinting, bracing positioning, strengthening muscules, rest when needed
- Improve neuromuscular control, strength, endurance: low intensity and low impact
- improve balance:
- improve physical conditioning: low impact aerobic exercise
10
Q
Osteoarthritis deformities in the hand and what would you expect an X-ray to show
A
- heberden’s nodes = DIP
- bouchard’s nodes = PIP
- X-ray = loss of joint space, osteophytes
11
Q
etiology for RA
A
- Chronic systemic inflammation autoimmune disease
- affects joints, ligaments, capsulesm synovium, CT, tendon sheaths, fascia, muscules, nerves, eyes, organs, skin
- multiple joints, symmetrica/Bilateral
- affects wrist, hands, MCP, PIP joints
- both genders any age
12
Q
What are the types of RA
A
- intermittent
- low grade
- progressive
- rapid progressive
least involved to most involved
13
Q
Types of RA
Intermittent
A
- exacerbations and remissions
- flare ups that come and go
14
Q
Tyeps of RA
Low grade
A
- mild no deformities
15
Q
Types of RA
Progressive
A
- worsening
- deformities
16
Q
Types of RA
Rapid progressive
A
- rapid wrosening with deformities
17
Q
RA
- destructive of joint tissue due to
A
- synovitis: inflammation of synovium
- erosion of joint articular cartilage and bone: thickened synvoial fluid, proteolytic enzymes, and pannus formation that smothers joint and imparis nutrition
- altered mechanics: altered support of the joint, laxity: bony and ligament destruction, muscule inhibtion and deformities
18
Q
Criteria for diagnosis of RA
Criteria for diagnosis of RA
A
- morning stiffness in and around joints lasting at least 1 hour
- at least 3 joints simultaneously have soft tissue swelling or fluid observed by physician
- swelling in the wrist, MCP or PIP joints
- symmetrical arthritis (B/L)
- Rheumatoid nodules
- serum rheumatoid factor
- radiographic changes inculding erosions or periarticular osteopenia in hand or wrist
diagnosis made if 4/7 criteria
1-4 must be present for 6 weeks
19
Q
RA active diesase periods Signs and symptoms
A
- synovitis: B/L in hands and wrist
- warm, swollen, painful, stiffness
- muscule weakness
- tenosynovitis (inflammation of tendon sheaths)
- joint erosion/joint instability
- may be assoicated with: anorexia, weight loss, fever, fatgue, sleep loss
20
Q
DX of RA
besides the classifications
A
- blood test for rheumatoid factor
- RF antibodies
- found in 80% of patients
21
Q
Describe these two in realtion to RA
- tenosynovitis
- joint erosion/instability
A
- Tenosynvitis:
- inflammation of tendon sheaths
- finger flexors, extensor tendonds
- can lead to tendon ruptures
- Carpal tunnel syndrome from the swollen tendons
- joint erosion leads to instability:
- subluxations
- deformities over time
- muscule imbalances
- dominant flexor tendon pull
- radiography - erosion, opsteopenia/osetoporosis
22
Q
synovial pseudocysts
A
- synvoial fluid going into “vaccum” in bone
23
Q
RA deformities
A
- MCP volar plate palmar dislocation
- wrist radial driff = sublux carpals ulnarly
- MCP ulnar drift = RCL weakening, ulnar pull of flexor tendons
24
Q
Swan neck deformity
A
- dorsal sublux of lateral bands
- hyperextension PIP
- flexed DIP
25
Boutonniere
- ruptured central band with lateral band drifts volarly
- PIP flexion
- DIP extension
26
MCP palmar dislocation
- MCP ruptured collateral ligament and volar plate
- stretched collateral ligament
- finger flexor pull, bowstringing forceof the flexor tendon and pulleys
27
Mallet Finger
flexed DIP
- extensor mechanism
- lateral bands rupture at DIP
- inability to actively extend DIP
| RA deformity
28
RA management during active periods
1. educate: rest, joint protection, orthosis, splint
2. decrease pain: modalities, massage, grades 1,2
3. minimize stiffness: PROM, AAROM, AROM with care (no active stretching)
4. minimize athrophy: place/hold isometrics to AAROM to AROM
5. prevent deformity: supportive and assistive equipment (dont do anything agressive and provide support)
29
Precuations with RA management during active periods
- fatigue
- increase pain
- dont over stress/stretch tissues
30
Contraindications with treatments for RA active periods
- overstretching of lax joints
- heavy resistance exercise
31
RA principles: joint protection, energy conservation sumarized
1. avoid deforming positions
2. short, frequent bouts of exercise: stop if discomfort, fatigue
3. alternate activites, rest to avoid fatigue
4. decrease activities if joint pain develops and exisits > 1 hour
5. maintain functional ROM, Strength, endurance
6. increase rest during flare-ups
7. avoid deforming positions, change positions every 20-30 minutes
8. use stronger, larger muscules and joints
9. use appropriate adaptive equipment
32
Guidelines for RA patients for exercise
- low intensity therapeutic exercise with rest
- reduce pain
- improving functional status
- high intensoity is not recommended due to exacerbating symptoms
33
Gouty arthritis
- hyperuricemia/excessive uric acid in blood
- deposits of sodium urate crystal in joint
- acute attack/onset
34
Gouty arthritis signs and symptoms
- seen in hands and feet
- joints are swollen, hot, inflammed
- held in open pack position
- severe pain with limited ROM
- comon in great toe MTP, gait deviation ER hip
35
Interventions for gouty arthritis
- medications: NSAIDs, colchicine, steriods
- joint protection - rest from function, splinting
- diet - avoid foods that trigger gout
- condition usually calms in weeks time
36
Differential diagnosis with UE presentation similar to arthritis
- cardiac,CHF: B/L swelling, clubbing for fingers
- diabetes, peripheral neuropathy
- sensory loss - UE glove pattern, peripheral nerve pattern
- tropic/vascular changes: shiny dry onion skin, hair loss, thick nails
