JOINTS Flashcards
Synarthrosis
• Fibrous, permits little or no mobility (eg The Skull)
AMPHIARTHROSIS:
cartilaginous joints, permits slight mobility (eg.
Vertebrae)
DIARTHROSIS:
- synovial joints (all diarthrosis)
- permits a variety of movements.
- (eg. Shoulder, Hip, Elbow, Knee etc)
OLIGOARTICULAR involvement
2- 4 joints groups affected
located dominantly at distal joints
generally asymmetrical
POLIARTICULAR involvement
> 5 joints affected symmetrical /asymmetrical dominant at upper or lower limbs periarticular involvement associated ± systemic involvement associated
Symptoms description
1. Symptoms description Severity of symptoms Sequence of symptoms Patterns of > Progression > Exacerbation > Remission
- Functional impact of the disease
- Effects of therapy (current / previous) on the illness course
- Compliance to therapy assessment
Symptoms
- Pain
- Stiffness
- Limitation of Motion
- Swelling
- Weakness
- Fatigue
1.Pain
most common complaint
Definition:
=subjective sensation that is difficult to define,
explain, or measure.
Localization → anatomical description
• ask the patient to point the area with a finger
1.Pain
• between joints may suggest
• more accurately if localized in
• small joints of the hands or feet > pain in larger jnt
(shoulder, hip, or spine)
• Superficial tissues
• less focal if arising from deeper structures
• if diffuse, variable, poorly described, or unrelated to
anatomic structures →
- Malingering, or
- Psychological problems
- Fibromyalgia
1.Pain- Characteristics (description)
- Intensity :variable
- Intense (↑”aching”) in a joint area suggests an
inflammatory disorder (arthritis)
- Sharp or “burning” (suggests neuropathy due to a
compression, eg. carpal tunnel syndrome) - Severity of pain: mild / moderate / severe
scale from 1 to 10 (determined by the patient)
!! If excessive, unbearable, in a patient who can otherwise perform usual activities is rather emotionally amplified - Duration: variable (the patient is asked when it appeared, if it was continuous or had periods of activity alternating with periods of remission)
- Type of onset: sudden/ insidious
Time of onset: the time of day when the pain begins / intensifies)
→ eg. nocturnal pain in gout (microcrystalline arthritis)
Durerea articulara- Caracteristici
Location
- ! Localized - joint pain is generally localized (felt
articular / periarticular)
or Iradiated (ex. A pain in the hip may cause also pain at the knee level on the same side)
Monoarticular/ Poliarticular
Symmetrical/ Asymmetrical
Example:
- symmetrical rheumatoid syndrome in rheumatoid arthritis
- asymmetric rheumatoid syndrome in reactive arthritis
Irradiate
distal: nerve compression syndromes (tunnel / compartment
syndrome)
referred pain
Pain assessment during activity/rest
inflammatory process→ Joint pain
• at Rest and
• with Movement (Activity)
- mechanical disorder (degenerative)
• Pain mainly during Activity
Persistence
- at the level of a certain joint or
- migratory character (moves from one joint
to another)
Stiffness
- discomfort perceived by the patient attempting
to move joints after a period of inactivity
Character
• develops after several hours of inactivity
• may resolve within a few minutes (Mild stiffness)
• may persist for many hours (RA or polymyalgia rheum.)
• usually transient
Morning stiffness
Inflammatory disease
- prodromal symptom of rheumatoid arthritis (RA)
- criterion for the diagnosis of RA (absence does not exclude)
NonInflammatory joint diseases
- short duration almost always (usually < 30 min)
- less severe than stiffness
- related to the extent of joint overuse (mechanical or
degenerative joint disease)
- resolve usually within a few days to limitation of the use of the affected joint
Limitation of Motion
Fixed
NOT transient
Does not vary
Limitation of Motion : important to detect
Type of onset
Abrupt = suggestive of a mechanical problem (tendon rupture)
Gradual = more common with inflammatory joint disease
The extent of limitation
Degree of Active and Passive motion limitation
Swelling
Determine:
• Where and When occurs
Information about
1. Factors that influence it
2. Onset and Persistence of the swelling
acutely developed →swelling is most painful
slowly developed is often much more tolerable
! Obese may interpret as swelling collections of adipose tissue over the elbow, knee, ankle
Weakness
- Loss of motor power or muscle strength
- Objectively demonstrable on physical examination
Assessment:
1.Distribution (distal / proximal)
2.Duration of weakness
3.Specific patterns
Patterns of weakness
musculoskeletal disorders
= Persistent > intermittent
neuromuscular disorders (myasthenia gravis)
= Initially good strength with subsequent weakness
inflammatory myopathies
= Weakness occurs in a Proximal distribution
(i.e., shoulders and hips rather than hands and feet)
neurologic disorder = Significant Distal involvement
Fatigue
An inclination to rest even though pain and weakness are not limiting factors
- sense of exhaustion, not muscle weakness, not pain
common complaint of patients with M&S disease
may be prominent even without activity in rheumatic dis.
Fatigue : Differentiation from stiffness + weekness
- Stiffness is a discomfort during movement
- Weakness is an inability to move normally, especially
against resistance
Fatigue : Differentiation from Malaise
Malaise
- is an indefinite feeling of lack of health
- occurs at the onset of an illness
- often occurs with fatigue but is not a synonymous
Fatigue & malaise can be seen in
the absence of identifiable organic
disease, and anxiety, tension, stress, and emotional factors can play a role.
JOINTS- CLINICAL EXAMINATION
Inspection – Palpation of: bony landmarks related joint and soft-tissue structures – Range of motion assessment – Special maneuvers to test specific movements
JOINTS - INSPECTION
- joint Symmetry
- joint Alignment
- bony Deformities
JOINTS
INSPECTION AND PALPATION
skin changes of surrounding tissues
– nodules
– muscle atrophy
– Crepitus = audible and/or palpable crunching during movement of tendons or ligaments over bone
JOINTS EXAMINATION
RANGE OF MOTION / MANEUVERS
Active mov. (i.e. movements performed by the patient on their own)
Passive mov. (i.e. movements performed by the examiner)
Resisted mov. (i.e. movements against resistance)
! always compare one side with the other
JOINTS EXAMINATION
RANGE OF MOTION
General rule: – muscular / tendon problems suggested by reduced active movements, that improve on passive movement – intra-articular disease suggested by reduced range of movements both active and passive
Temporomandibular Joint (TMJ) INSPECTION + PALPATION
place the tips of your index fingers just
in front of the tragus of each ear and ask the
patient to open his or her mouth. The fingertips
should drop into the joint spaces as the mouth
opens
Temporomandibular Joint (TMJ) RANGE OF MOTION
– Opening / closing
– Protrusion / retraction
– Lateral / Side to side motion
Flexion
Normal range – usually 180 degrees
Extension
Normal range ~
usually 50 degrees
Abduction
(Normal range ~
usually 180 degrees)
Adduction
(Normal range ~
usually 45 degrees)
External rotation ( Shoulder )
(Normal range ~
usually 90 degrees)
Internal rotation ( Shoulder )
(Normal range ~
usually 50 degr)
PAINFUL SHOULDERS
1.Pain
2.Pinching
3.Stiffness →
Pain characters
Pain characters
Location: upper arm Radiation into the - forearm - hands - fingers Worsening at night, making sleeping a painful and difficult event Pathology: PAINFUL SHOULDERS
when raising the arm
ELBOW
INSPECTION + PALPATION
epicondyles (medial and lateral) - olecranon process of the ulna Identify: - Tenderness (Press on the epicondyles) - Displacement of the olecranon
- grooves between the epicondyles and the olecranon Identify: - tenderness - swelling - thickening
ELBOW
RANGE OF MOTION
Flexion / extension at the elbow
– Pronation / supination of the forearm
The wrist and hand
INSPECTION for
- Swelling over the palmar and dorsal surfaces of the wrist and hand
- Deformities of the wrist, hand, or finger bones
- Angulation from radial or ulnar deviation
- Thickening of the flexor tendons
- Flexion contractures in the fingers
- Observe the thenar and hypothenar eminences
The wrist and hand
PALPATION
wrist / distal ulna and radius • anatomic snuffbox • 8 carpal bones • each of the 5 metacarpals • Phalanges (proximal, middle, and distal) Look for: tenderness swelling
WRIST
RANGE OF MOTIONS
- Flexion
- Extension
- Ulnar / radial deviation
The wrist and hand
Pathologic finding
1. Dupuytren’s contracture
fixed flexion
contracture of the hand where the fingers bend towards the palm and cannot be fully extended (straightened)
The wrist and hand Pathologic finding ( 2, 3)
- Herbeden’s nodes (distal Phalanges)
3. Bouchard’s nodes (interPhalangian)
The wrist and hand
Pathologic finding
4. Rheumatoid Arthritis
- swollen hand (early RA)
- ulnar deviation (late RA)
The spine
INSPECTION
(From the side)
spinal curvatures → 1= Cervical lordosis 2=Thoracic kyphosis 3= Lumbar lordosis 4= Sacral kyphosis
The spine
INSPECTION
From behind
1="Vertebra prominens" Spinous process of C7 2= 2nd Lumbar vertebra 3= L4-5 inter vertebral space 4= Iliac crests 5= Dimples of Venus (fossae lumbales lateralis) / Sacroiliac joints
The spine
PALPATION
tenderness
the spinous process /
the paraspinal muscles /
the sacroiliac joints
The spine
Schober’s test
!!! measures the degree of flexion of the spine
Mark the spine at the lumbosacral junction, then 10 cm above and 5 cm below this point. A 4-cm increase between the two upper marks is
normally seen.
!!! Increases less < 4cm in ankylosing spondylitis
Lasegue Maneuver
- The sciatic nerve elongation maneuver performed in clinostatism
- It involves raising the pelvic limb in extension to an angle of 90 degrees
- If present, pain apear at an angle of less than 30 degrees
HIP INSPECTION
Assess – level of the iliac crests – leg length discrepancy – muscle wasting – scar
HIP PALPATION
- tenderness
- heat
- swelling ] ->
around the inguinal areas and the greater trochanter
area
Measurement of legs length
– between the anterior iliac spine to the tip of the medial mallous, with the anterior spines lying at the same transverse level
! compare one side to the other
HIP FLEXION + EXTENSION
Normal range ~ 120 degree
ADDUCTION
Normal range of movement
~ 30 degrees)
ABDUCTION
Normal range of movement
~ 45 degrees
HIP EXTERNAL ROTATION
Normal range of movement
~ 60 degrees
HIP INTERNAL ROTATION
(Normal range of movement
~ 45 degrees)
The knee and lower leg
INSPECTION
walking & standing (eg.walk with a limp)
Asses for: • muscle wasting • bowing (varus) deformity • knock-kneed (valgus) deformity • sign of inflammation (eg.red or swollen)
The knee and lower leg
INSPECTION
- genu varum
(Varus deformity of the knee) - scar & staples (recent) after a total knee replacement
The knee and lower leg
PALPATION
– temperature
– Tenderness (Bend the knee to 90 degrees & feel around the medial & lateral joint lines)
• the patella
• quadriceps tendon
• prepatellar & collateral ligaments
– popliteal (Bakers) cyst: back of the knee
The knee and lower leg
Special maneuvers
Assessment of fluid in the knee join (3 tests)
–1) The Bulge Sign (for minor effusions)
–2) The Balloon Sign (for major effusions)
Compress the suprapatellar pouch against the femur.
Feel for fluid entering (or ballooning into) the spaces next to the patella under your right thumb and index finger.
3) Ballotting the patella-large effusions
Compress the suprapatellar pouch and “ballotte” or push the patella sharply against the femur.
Watch for fluid returning to the suprapatellar pouch.
Knee + lower leg
Range of motions
– Flexion/extension
– Internal/external rotation
Crepitus is usually indicative of
degenerative knee disease (osteoarthritis)
The ankle + foot
Range of motions
– Flexion / extension at the ankle (tibiotalar) joint
– In the foot: inversion / eversion
The ankle + foot
- Arthritis , ligaments , injury or infection of the ankle
- Achilles tendinitis
- Bursitis
- Plantar fasciitis
- Rheumatoid arthritis
- Gout
Arthritis, ligament injury, or infection of the ankle
- localized tenderness
- pain on mobilization
Achilles tendinitis
- tenderness
- partial tear from trauma
- rheumatoid nodules in Achilles tendon
Bursitis
- tenderness
Plantar fasciitis
pain over the plantar fascia
Rheumatoid arthritis
tenderness on compression is an early sign
Gout
acute inflammation of the first metatarsophalangeal joint (pain, decreased movements, edema, erythema)
DIAGNOSIS
AGE
young: SLE, rheumatic fever, and Reiter’s syndrome
middle age: fibromyalgia
old age: osteoarthritis, polymyalgia rheumatica
SEX
men: Gout, spondyloarthropathies
women: rheumatoid arthritis, fibromyalgia
RACE
whites: giant cell arteritis, and Wegener disease
blacks: sarcoidosis and systemic lupus erythematosus (SLE)
FAMILY HISTORY
Familial aggregation:
RA, ankylosing spondylitis, gout,
JOINT- EXTRINSEC PAIN
- Cellulitis - typical red streaks and swelling
- Bursitis
JOINT PAIN – Intrinsic conditions
Degenerative disorders
Osteoarthritis
JOINT DISEASES = ARTHRITIS
- Osteoarthritis
- Autoimmune diseases
- rheumatoid arthritis
- psoriatic arthritis
- reactive arthritis - Septic arthritis
- Gouty arthritis/ Pseudogout
OSTEOARTHRITIS
DEFINITION
- Degeneration
- Progressive loss
of cartilage within the joints - Underlying Bone damage
- New Bone formation at the margins of the cartilage
OSTEOARTHRITIS
Pattern of Spread: – Additive or only 1 joint may be involved Onset: usually Insidious Progression and duration – Slowly progressive, with temporary exacerbations after periods of overuse
Associated symptoms: – Swelling: small effusions may be present, especially in the knees – Redness : rarely – Warmth : seldom – Tenderness : Possibly Stiffness: After inactivity Limitations of motions: often develops Generalized symptoms: ABSENT
RHEUMATHOID ARTHRITIS
- synovial membranes inflammation
- cartilage erosion
- bone erosion
- ligaments and tendons damage
- Systemic involvment
Joint involvement pattern in
RHEUMATHOID ARTHRITIS
- Pattern of Spread:
– Symmetrically
– Additive: progresses to other joints while persisting in the initial ones - Onset:
– Insidious Usually - Progression and duration:
– Often chronic, with Remissions and Exacerbations
Associated symptoms
–Swelling of synovial tissue in joints or tendon
sheaths + Subcutaneous nodules
– Redness, Warmth and Tenderness:
seldom red, often warm, tender
–Stiffness: prominent, often for an hour or more in
the morning, also after inactivity
–Limitation of Motion: often develops
–Generalized Symptoms: weakness,
fatigue, weight loss,and increased fever
Joint involvement pattern in
RHEUMATHOID ARTHRITIS
– Hands (PIP / MCP joints) – feet (MTP joints) –Wrists – Knees –Elbows – Ankles
Early rheumatoid arthritis
MCP joints
Swollen
Warm
Red
Late RA
Deformities present.
Swan neck deformity of the thumb.
Ulnar drift of the MCP joints.
Subluxation of the PIP joints.
RHEUMATHOID ARTHRITIS
DIAGNOSIS CRITERIA
- Morning stiffness
- Arthritis of 3 or more joint areas
- Arthritis of hand joints
- Symmetric arthritis
- Rheumatoid nodules
- Serum RF
- Radiographic (erosions or bony decalcification on hand and wrist
PSORIATIC ARTHRITIS findings
10-30% of people suffering from psoriasis Inflammatory arthritis Associated signs: Psoriatic Nail lesions splitting of nails → onycholysis Tendinitis =‘sausage-like’ swelling of digits ~ dactylitis
Reactive Arthritis
autoimmune condition that develops in
response to an infection in another part of the
body (genitourinary or gastrointestinal infections)
Reiter ́s syndrome = 3 symptoms combination:
Arthritis (inflammatory) of large joints RTCD
Eyes inflammation (Conjunctivitis and Uveitis)
Urethritis
Septic arthritis
DEFINITION joint infection
PATHOGENY:
dissemination of pathogens by blood
abscesses or wound infections osteomyelitic focus
• dissemination by Contiguity (adjacent soft tissue infection)
direct entry via penetrating trauma
iatrogenic means
ETIOLOGY
Bacteria commonly involved:
Staph. aureus, Streptococci, E coli, M. tuberculosis, Salmonella spp.
Gout
Caused by Deposition of Uric Acid Crystals in the joint that results in subsequent joint inflammation Characterized by – Pain: (burning) severe, sudden, unexpected D – Swelling T – Redness R – Warmth C – Stiffness – Low-grade Fever may also be present occurs commonly in Men in their toes Longstanding Hyperuricemia
Other sign
- Tophi = uric acid crystal deposits in other tissues
– Ear helix
– Knees, elbows, hands
Arthritis in Rheumatic Fever
systemic illness - autoimmune response group A β hemolytic streptococcal pharyngitis - rheumatic heart disease, most serious complication Clinical manifestation Major diagnostic criteria 1. Carditis 2. Polyarthritis 3. Chorea 4. Subcutaneous nodules 5. Erythema marginatum
Minor diagnostic criteria
- Fever
- Arthralgia
- Prolonged PR interval on Ecg
- Elevated acute-phase reactants
2 M / 1 M+ 2
Joint involvement pattern in
Rheumatic Fever
Polyarthritis
• earliest manifestation of RF (70-75%)
• begins in the large joints of the lower extremities
(ie, knees, ankles)
- Migratory → migrates to other large joints in the lower or upper extremities (ie, elbows, wrists)
- NOT Additive
- Generally fully recover of joint
- IF multiple attacks → destructive arthritis (Jaccoud arthritis)
Joint involvement pattern in
Rheumatic Fever
Arthritis symptoms + signs
Symptom • Pain out of proportion to clinical findings reaches maximum severity in 12-24 hours persists for 2-6 days
Signs • Swelling • Warmth • Redness • Limited range of motion
Ankylosing Spondylitis
chronic and Progressive form of Seronegative arthritis • autoimmune disease - arthritis of the spine - start 20 - 40 y - Males >>> females Risk factors • Family history of AS • Male gender
Ankylosing Spondylitis
Symptoms
LOW BACK PAIN
• centered over the sacrum
• radiate to the groin and buttocks and down the legs
• comes and goes
• worse at night, in the morning, or when Pt are Not active
• Awake from sleep
• typically gets better with activity or exercise
• SUBSTRATE: bilateral sacroiliitis
Ankylosing Spondylitis
less common symptoms
- Eye inflammation or uveitis
- Peripheral joint Pain, Heel pain, Hip pain and Stiffness
- Fatigue
- Slight Fever
- Weight loss
- Loss of appetite
Ankylosing Spondylitis
Joint involved
axial skeleton particularly
• sacroiliac and spinal facet joints
+ Extraspinal involvement
Ankylosing Spondylitis
Symptoms and Range of movement suggest diagnosis
- Low back pain: present for more than 3 months,
improved by exercise but not relieved by rest. - Limitation of lumbar spine motion (sagittal &
frontal) - Limitation of chest expansion relative to normal
values for age and sex.
Ankylosing Spondylitis Physical examination (signs)
- Spine & sacroiliac joints
• Loss of lateral flexion of the lumbar spine early
• tenderness response during percussion over the sacroiliac joints
• pain response by springing the pelvis
2. Peripheral joints • restriction of joint motion (Synovitis) Entheses tenderness (entheses are sites of attachment to bone of ligaments, tendons, and joint capsules) ↓ Chest expansion → costovertebral joints involved • Diaphragmatic breathing (ballooning of the abdomen during inspiration)
Ankylosing Spondylitis
Tests to measure spinal restriction
1.Touching the toes (difficult)
2.Schober test (<4 cm)
3.Chest expansion measurement (↓)
in AS the spine
→ completely rigid
→ with loss of the normal curvatures and
→ reduced movement
