Multisystem Flashcards
What are the common areas affected in RA and common deformities/issues it can cause at each joint?
C-spine - weaken or rupture transverse ligament
Shoulder - sublux/dislocations, RC or biceps tendinitis or rupture
Elbow - RA nodules, flexion contracture, ulnar nerve entrapment
Wrist - dorsal subluxation of distal ulna, extensor tendon ruptures, ulnar drift, carpal tunnel
MCP/PIP - z-deformity of thumb, swan neck, boutonniere
Knee - valgus, Baker’s cyst, flexion contracture
Ankle and foot - hindfoot valgus, forefoot planus, tarsal tunnel
MTP - hallux valgus, MTP subluxations and metatarsalgia
Toe - claw toe, hammer toe, mallet toe
What are the criteria to diagnose RA?
4/7:
- symmetrical arthritis
- morning stiffness > 1 hour
- at least 3 joints swollen simultaneous
- one of the joints must be wrist, MCP or PIP
- RA nodules
- Rheumatoid factor (RF)
- X ray shows erosions and bony decalcification
What are special questions to ask during a subjective ax of RA?
Neck problems (5Ds, 3Ns, facial parasthesia or quadrilateral parasthesia)
Hot swollen joints
Focal vs diffuse weakness
Burning sensation, numbness or parasthesia
History of trauma
What are the 4 components of the Standard Assessment of Joint Inflammation? What are the indications of a damaged joint?
Lab result: RF
Duration of morning stiffness
Bilateral grip strength
Active joint count - effusion, joint line tenderness, stress pain
Damaged joint = subluxation/deformity, crepitus, PROM loss of > 20%, ligament laxity
TMJ Joint Count
Effusion - finger tips in hollow area ant to ext auditory meatus, hollow will fill when opens mouth if effusion present
Joint line tenderness - pressure to joint line with tips of fingers
Stress pain - open mouth as much as possible
SC Joint Count
Effusion - palpate lateral to sternum using thumbs
Joint line tenderness - AP pressure over joint line
Stress pain - unreliable
AC Joint Count
Effusion - difficult to assess
Joint line tenderness - AP pressure over joint line
Stress pain - horizontal adduction or shoulder shrug
GH Joint Count
Effusion - palpated over ant joint line/bicipital tendon area
Joint line tenderness - unreliable
Stress pain - shoulder in 60° abd and IR/ER with OP
Elbow Joint Count
Effusion - elbow in 90° flex and palpate both sides of olecranon with thumbs or bulge sign present at prox radius when moving from 45° flex to full ext
Joint line tenderness - elbow at 45° flex, pressure on either side of olecranon
Stress pain - full passive flex/ext and OP
Wrist Joint Count
Effusion - wrist in neutral, feel over radiocarpal joint or distal ulnar using 2 thumb method
Joint line tenderness - wrist in neutral, pressure over dorsal radiocarpal joint
Stress pain - full passive flex/ext and OP
CMC of thumb Joint Count
Effusion - difficult to ax
Joint line tenderness - pressure over CMC joint line
Stress pain - unreliable
MCP Joint Count
Effusion - slightly flexed with 2 thumb technique
Joint line tenderness - same position and apply pressure with both thumbs
Stress pain - full ext and OP
PIP Joint Count
Effusion - 4 finger technique (press AP and feel for fluid in ML)
Joint line tenderness - pressure ant to collateral ligaments
Stress pain - full flex/ext and OP
DIP Joint Count
Effusion - 4 finger technique
Joint line tenderness - pressure ant to collaterals
Stress pain - full flex/ext and OP
Hip Joint Count
Effusion - unreliable
Joint line tenderness - unreliable
Stress pain - supine with hips and knees to 90, IR/ER and OP
Knee Joint Count
Effusion - bulge test
Joint line tenderness - knee in 60 and pressure over joint line
Stress pain - full flex/ext and OP
Tibiotalar Joint Count
Effusion - 2 thumb technique to dorsal ankle beside tib ant tendon and EHL
Joint line tenderness - over joint line with 2 thumbs with knee slightly flexed
Stress pain - knee flexed, ankle full DF and OP
Subtalar Joint Count
Effusion - unreliable
Joint line tenderness - unreliable
Stress pain - ankle in DF, move calcaneus over talus into IR/ER and OP
Midtarsal Joint Count
Effusion - unreliable
Joint line tenderness - unreliable
Stress pain - ankle in DF, midfoot into inv/ev and OP
MTP Joint Count
Effusion - unreliable
Joint line tenderness - slightly flexed and pressure over joint line
Stress pain - end range flexion + traction and OP
PIP and DIP Joint Count (Toes)
Effusion - difficult to assess
Joint line tenderness - pressure on med and lat aspects
Stress pain - full flexion and OP
What are the most common areas affected by OA? What are common deformities in these areas?
C-spine - osteophytes (can cause nerve root compression)
L-spine - osteophytes (can cause nerve root compression)
Hips - decreased joint space
Knees - varus deformity
1st MTP - osteophytes and hallux valgus
What are common symptoms of OA?
Pain is better with movement AM stiffness 15-20min Crepitus Decreased ROM Muscle weakness Swelling Local symptoms
What are special Qs to ask someone with OA during subjective?
Neck problems (5Ds, 3Ns, facial parasthesia, quad parasthesia) Back problems (bowel, bladder, coughing, sneezing, b/l weakness to LE, numbness/para/burning down LE
What are common symptoms of AS?
Gradual onset of pain and stiffness at base of spine
Symptoms may spread to gluteal region
Worse in morning (30-40min)
Pain wakes pt up at night
What are common x-ray findings for AS?
Sacroiliitis, syndesmophytes in spine, increased Tsp kyphosis, enthesitis, bone formation in lig/fascia
What are special questions to ask someone with AS in subjective?
Vision (iritis is common) Bowel or bladder SOB (rigid thorax, pulmonary involvement) Morning stiffness Does pain wake them at night
What are common physical examination findings for AS?
Dec ROM in spine Tsp kyphosis Dec lumbar lordosis Impaired balance due to postural changes Upward gaze due to cervical flexion deformity SIJ tender on palpation Dec chest wall expansion
What are the 5 components of the BASMI?
1) Cervical rotation - measure with goniometer
2) Tragus to wall - against wall, retraction of Csp and measure distance from tragus to wall
3) Modified Schober’s (PSIS, 10cm above and 5cm below) - forward bend without knee/hip compensation
4) Finger to floor lateral flexion - against wall and measure distance when side flexing
5) Intermalleolar distance - lying supine and separate legs as far and measure distance
What are the criteria to diagnose SLE?
4+ criteria to diagnose:
- Malar/butterfly rash on face
- Discoid rash
- Photosensitivity
- Mucosal ulcers
- Arthritis (2+ peripheral joints, non erosive)
- Serositis (chest pain when breathing, pleura or pericardia)
- Renal (proteinuria)
- Neurologic (seizures, psychosis)
- Hematologic (dec WBC/RBC/platelet)
- Immunologic (abnormal antibody count)
- ANA+
What are common symptoms of SLE?
- General malaise
- Fever
- Joint pain
- Red rash over face
- Headaches
- Raynaud’s in fingers
- Pain wakes pt up at night
What are pre-prosthetic goals for amputees?
Prevent contractures (TT - hip flexion, knee flexion; TF - hip flexion, abd, ER)
Decrease edema (elevation, compression)
Prevent adhesion of incision
Desensitize residual limb
Strengthen muscles for prosthesis (TT - hip musculature, knee extensors; TF - hip ext, abd, add)
What are goals for burns patients?
Prevent pulmonary complications (positioning, DBE, cough/huff, mobilize)
Prevent contractures and edema control (positioning, splinting, elevation)
Promote independent mobility (early ambulation or bed exercises)
What is appropriate joint positioning to prevent contractures post burn?
Axilla - shoulder abd, flex, ER
Neck - neutral or ext
Ant elbow - extension and supination
Wrist and hand - MCP in flexion, PIP/DIP ext, thumb abducted, wrist 20° ext
Hip - extension, neutral position, 10° abd, knee straight, feet neutral
What are the treatment goals for RA? What are treatment strategies to accomplish these goals?
Decrease pain - ice in flare ups; heat in non flare ups, rest/splinting, joint protection principles, footwear
Decrease swelling - ultrasound, AROM, RICE
Increase ROM - ROM exercises (AROM, PROM, AAROM)
Increase function and functional capacity - promote use of mobility aid, education re: transfers, ambulation, devices, aerobic and strengthening exercise during non flare ups
Self management - knowledge of disease, joint protection principles, energy conservation
What is contraindicated during RA flare ups?
Heat and stretching
What are joint protection principles for RA?
Pain guided movements Distribute load over several joints Avoid positions of deformity Avoid poor postures Use of largest joints available to perform a task
What are treatment options for OA?
Education
Activity and exercise - strengthening (NWB if irritable), aerobic (low impact), flexibility
Weight loss
Pain reduction - heat/cold, TENS, bracing, footwear, assistive devices
What are exercise and education options for patients with AS?
Incentive spirometry Diaphragmatic breathing Aerobic exercise Spinal mobility exercises (no flexion) Postural correction exercise Flexibility Education re: fatigue and pain managament, sleep hygiene, assistive devices, work/home modifications
