OHCEPS - The Locomotor System Flashcards
1
Q
Fibrous joints?
A
- Held together by fibrous (collagenous) connective tissue and are “fixed” or “immoveable”.
- They do not have a joint cavity. Examples include the connections of the skull bones.
2
Q
Cartilagenous joints?
A
- Held together by cartilage, are slightly moveable and again have no cavity.
- An example is the vertebral joints.
3
Q
Synovial joints?
A
- Covered by cartilage with a synovial membrane enclosing a joint cavity.
- These joints are freely moveable and are the most common type of joint functionally, being typical of nearly all the joints of the limbs.
4
Q
Role of the inner synovial membrane of a synovial joint?
A
Secretes synovial fluid –> number of functions:
- Lubrication
- Supply of nutrients to the cartilage
5
Q
Synovial fluid contains?
A
Phagocytic cells that remove microbes and debris within the joint cavity.
6
Q
Types of synovial joints?
A
- Hinge
- Ball and socket
- Pivot
- Gliding
- Saddle
7
Q
Hinge synovial joint?
A
Movement occurs primarily in a single plane (eg elbow, knee, and interphalangeal joints.
8
Q
Ball and socket synovial joint?
A
Allows movement around 3 axes (flexion/extension, abduction/adduction, and rotation).
Examples are the shoulder and hip.
9
Q
Pivot synovial joint?
A
A ring of bone and ligament surrounds the surface of the other bone allowing rotation only.
Examples –> Atlanto-axial joint at C1 and C2 vertebrae and the connection between the radius and ulna.
10
Q
Gliding synovial joint?
A
Flat bone surfaces allow side-to-side and backwards and forwards movements.
Examples –> Between carpals, tarsals, sternum and clavicle and the scapula and clavicle.
11
Q
Saddle synovial joints?
A
Similar to a hinge joint but with a degree of movement in a second plane (eg base of thumb).
12
Q
Special movements - Inversion?
A
Tilting the soles of the feet inwards to face each other.
13
Q
Special movement - Eversion?
A
Tilting the soles of the feet outwards away from each other.
14
Q
Special movements - Protraction?
A
Moving the mandible forward.
15
Q
Special movements - Retraction?
A
Moving the mandible backwards.
16
Q
Character of pain in the locomotor system?
A
- Bone pain is typically experienced as boring, penetrating and often worse at night.
- Pain associated with a fracture is usually sharp and stabbing in nature and often exacerbated by movement.
- Shooting pain is suggestive of nerve entrapment (eg disc protrusion).
17
Q
Bone pain - etiology?
A
- Tumor
- Chronic infection
- Avascular necrosis
- Osteoid osteoma
18
Q
Acute onset of bone pain leads us to?
A
Manifestation of infection such as septic arthritis or crystal arthropathies (eg gout).
19
Q
Chrondromalacia patellae?
A
This arises due to softening of the patellar articular cartilage and is felt as a patellar ache after prolonged sitting.
Usually seen in young people.
20
Q
Osteochrondritis dissecans?
A
Usually associated with trauma resulting in an osteochondral fracture which forms a loose body in the joint with underlying necrosis.
21
Q
Osgood-Schlatter’s disease?
A
Arises as a result of a traction injury of the tibial epiphysis which is classically associated with a lump over the tibia.
22
Q
Etiology of arthralgia in adults - Knee?
A
- Osteoarthritis
- Referred from the hip
- Chondomalacia patellae
- Trauma
- Osteochrondritis dissecans
- Bursitis
- Tendonitis
- Osgood-Schlatter’s disease
- RA
- Infection
- Malignancy
23
Q
Etiology of arthralgia in adults - Hip?
A
- Osteoarthritis
- Referred pain - eg from a lumbar spine abnormality
- Trauma
- RA
- Infection
- Hernia
- Tendonitis
- Bursitis
24
Q
Etiology of shoulder pain in adults?
A
- Rotator cuff disorders (eg tendonitis, rupture, adhesive capsulitis/frozen shoulder).
- Referred pain - eg cervical, mediastinal, cardiac.
- Arthritis - glenohumeral, acromioclavicular.
25
Etiology of elbow arthralgia in adults?
1. Lateral epicondylitis (tennis elbow)
2. Medial epicondylitis (golfer's elbow)
3. Olecranon bursitis
4. Referred pain from neck/shoulder (eg cervical spondylolysis)
5. Osteoarthritis
6. RA
26
Etiology of mechanical/degenerative back pain in adults?
1. Arthritis
2. Trauma
3. Disc prolapse
4. Osteoporosis
5. Infection
6. Ankylosing spondylitis
7. Spondylolisthesis
8. Lumbar spinal/lateral recess stenosis
9. Spinal tumors - Especially metastases from lung, breast, prostate, thyroid, kidney.
10. Metabolic bone disease.
27
Stiffness is?
A subjective symptom which must be explored in detail to establish exactly what the patient means.
--> It is the inability to move the joints after a period of rest. It may be due to mechanical dysfunction, local inflammation of a joint or a combination of both.
28
If stiffness predominates over pain, consider?
Spasticity or tetany.
| Look for hypertonia and other motor neuron signs.
29
Stiffness - what to ask the patient?
1. When is the stiffness worst? (early morning etc...)
2. Which joints are involved? Is the stiffness generalized?
3. How long does it takes them to "get going" in the morning?
4. How is the stiffness related to rest and activity?
30
Locking is?
This is the sudden inability to complete a certain movement and suggests a mechanical block or obstruction usually caused by a loose body or torn cartilage within the joint (often secondary to trauma).
31
Swelling of the joint - Etiology?
A variety of factors - Including:
1. Inflammation of the synovial lining.
2. Incr. in the volume of synovial fluid
3. Hypertrophy of bone
4. Swelling of structures surrounding the joint.
32
Swelling is particularly significant when?
In the presence of joint pain and stiffness.
33
Swelling - what is essential to be established?
1. Which joints are affected (small or large)?
2. Is the distribution symmetrical?
3. What was the nature of onset of swelling?
4. Are the joints ALWAYS swollen or does it come and go (and when)?
5. Is there any associated pain?
6. Do the joints feel hot to touch?
7. Is there erythema? (common in infective, traumatic and crystal arthropathies)
8. Have the joints in question sustained any injuries?
34
Deformity - What is essential to be established?
1. The time frame over which the deformity has developed.
2. Any associated symptoms such as pain and swelling.
3. Any resultant loss of function? (What is the patient now unable to do with the joint in question?)
35
Acute deformity usually associated with?
Fracture or dislocation.
36
Chronic deformity usually associated with?
Bone malalignment and may be:
1. Partial/subluxed
2. Complete/dislocated
37
Weakness - what to ask?
Always enquire about the presence of localized or generalized weakness which suggests a peripheral nerve lesion or a systemic cause, respectively.
--> Consider that the weakness may be neurogenic or myopathic in origin.
38
Sensory distribution - what to ask?
Ask about the exact distribution of any numbness or paresthesia as well as documenting any exacerbating and relieving factors.
39
Some major extra-articular features of several locomotor disorders?
1. Systemic symptoms - fever, weight loss, fatigue, lethargy.
2. Skin rash
3. Raynaud's
4. GI (eg diarrhea and resultant reactive arthritis or enteropathic arthritis secondary to inflammatory bowel disease).
5. Urethritis (Reiter syndrome)
6. Eye symptoms
7. Cardiorespiratory --> Breathlessness (pulm. fibrosis?), pericardial and pleuritic chest pain, AV regurgitation, and spondyloarthropathies.
8. Neurological --> Nerve entrapment, migraine, depression, stroke.
40
Joint deformity - Valgus?
The bone or part of limb distal to the joint is deviated LATERALLY.
41
Joint deformity - Varus?
The bone or part of limb distal to the joint is deviated MEDIALLY.
42
PMH - What to ask about?
Ask about ALL previous medical and surgical disorders and enquire specifically about any previous history of trauma or musculoskeletal disease.
43
The rest of the history - FHx?
It is important to note any FHx of illness, especially those locomotor conditions with a heritable element:
1. Osteoarthritis
2. RA
3. Osteoporosis
- -> The seronegative spondyloarthropathies (eg ankylosing spondylosis) are more prevalent in patients with the HLA-B27 haplotype.
44
The rest of the history - DHx?
1. Full DHx including all prescribed and OTC medications.
2. Attempt to assess the efficacy of each treatment including those past and present.
3. Ask about any side effects of any drugs taken for locomotor disease.
4. Ask also about medication with known adverse musculoskeletal effects.
5. Drugs that may increase the risk of developing TB, HIV, hep --> All of which can cause musculoskeletal complaints.
45
Long-term side effects of steroid therapy?
1. Osteoporosis
2. Myopathy
3. Infections
4. Avascular necrosis
46
Statins - Adverse effects?
1. Myalgia
2. Myositis
3. Myopathy
47
ACEIs - Side effects?
Myalgia
48
Anticonvulsants - Side effects?
Osteomalacia
49
Quinolone - Side effects?
Tendinopathy
50
Diuretics - Side effects?
1. Aspirin
2. Alcohol
3. Gout
51
SLE drugs?
1. Procainamide
2. Hydralazine
3. Isoniazid
52
Social history - Certain occupations?
1. Repetitive strain injury
2. Hand-vibration syndrome
3. Fatigue fractures
- -> Dancers + Athletes.
53
Social history - Ethnicity?
Relevant as there is an overrepresentation of lupus and TB in the Asian population, both of which are linked to a variety of locomotor complaints.
54
The rest of the history - Sexual history?
Where appropriate, take a sexual history. This is important because reactive arthritis, or Reiter's syndrome may be cause by STDs (Chlamydia, gonorrhoeae).
55
The locomotor system - Outline examination?
1. Elbow
2. Shoulder
3. Spine
4. Hip
5. Knee
6. Ankle
7. Foot
56
Examination framework?
Examination of each joint should follow the standard format:
1. Look
2. Feel
3. Move (passive, active)
4. Measure
5. Special tests
6. Function
57
The GALS screen?
```
G = Gait
A = Arms
L = Legs
S = Spine
```
58
GALS screen - Role?
Was devised as a quick screen for abnormality in the absence of symptoms.
59
GALS screen - Gait?
1. Watch the patient walk.
2. There should be symmetry and smoothness of movements and arm swing with no pelvic tilt and normal stride length.
3. Patient should be able to start, stop and turn quickly.
60
GALS - Arms (sitting on couch) - Inspection?
1. Look for muscle wasting and joint deformity at the shoulders, elbows, wrists and fingers.
2. Squeeze across the 2nd-5th metacarpals - there should be no tenderness.
61
Arms - Shoulder abduction?
"Raise your arms out sideways, above your head". Normal range 170-180degrees.
62
Arms - Shoulder external rotation?
"Touch your back between your shoulder blades".
63
Arms - Shoulder internal rotation?
"Touch the small of your back". Should touch above T10.
64
Arms - Elbow extension?
"Straighten your arms out". Normal is 0 degree.
65
Arms - Wrist and finger extension?
The prayer sign.
66
Arms - Wrist flexion and finger extension?
The reverse prayer sign.
67
Arms - Power grip?
"Make a fist" - Should hide fingernails.
68
Arms - Precision grip?
"Put your fingertips on your thumb"
69
GALS - Legs (lying on couch) - Inspection?
1. Look for swelling or deformity at the knee, ankle and foot as well as quadriceps muscle wasting.
2. Squeeze across the metatarsals - there should be no tenderness.
70
Legs - Hip and knee flexion?
1. Test passively and actively.
| 2. Normal hip flexion is 120, normal knee flexion is 135.
71
Legs - Hip internal rotation?
Normal is 90 at 45 flexion.
72
Legs - Knee?
Bulge test and patellar tap.
73
Legs - Ankle?
Test dorsiflexion (normal 15) and planarflexion (normal 55).
74
GALS screen - Spine (standing) - Inspection?
From behind --> Look for scoliosis, muscle bulk at the paraspinals, shoulders and gluteals, level iliac crests.
From the side --> Look for normal thoracic kyphosis and lumbar and cervical lordosis.
75
Spine - Tenderness?
Feel over the mid-supraspinatus --> there should be NO tenderness.
76
Spine - Lumbar flexion?
"Touch your toes".
| Normal is finger-floor distance Schober's test.
77
Spine - Cervical lateral flexion?
"Put your ear on your shoulder".
78
Elbow - Look?
1. Any mobility aids or other clues.
2. Ask the patient to stand, make sure both upper limbs are exposed and look at the patient from top to toe.
3. Inspect the elbow from side to side and note:
a. Malalignment of the bones
b. Scars
c. Skin changes (eg psoriatic plaques)
d. Skin or subcutaneous nodules
e. Deformities
f. Muscle wasting
g. Swelling
79
Elbow - Look - Deformities?
Varus (cubitus varus): can be caused by a supracondylar fracture.
Valgus (cubitus valgus): can be caused by non-union of a lateral condylar fracture.
80
Elbow - Feel?
1. Always ask about PAIN before getting started.
2. Palpate the joint posteriorly and feel for:
a. Temperature
b. Subcutaneous nodules
c. Swelling
d. If fluid is present, attempt to displace it on either side of the olecranon.
e. Carefully palpate the joint margin for tenderness and note if it is localized to the medial epicondyle (golfer's elbow) or the lateral epicondyle (tennis elbow).
81
Elbow - Feel - Swelling?
1. Soft swelling may be due to olecranon bursitis.
2. Hard swellings suggests a bony deformity
3. Boggy swelling suggests synovial thickening (secondary to RA).
82
Elbow - Move?
1. Check that there is good shoulder function before attempting to assess elbow movements.
2. Remember to test passive movements (you do the moving) and active movements (patient does the moving) at each stage.
3. Ask the patient to place their arms on the back of their head.
4. Next assess elbow flexion and extension with the upper arm fixed --> Remember to compare with the opposite side.
5. With the elbows tucked into the sides and flexed to a right angle, test the radio-ulnar joints for pronation (palms towards floor) and supination (palms towards the sky).
83
Elbow - Measure?
Measure elbow flexion and extension in degrees from the neutral position (ie consider a straight elbow joint to be 0).
84
Elbow - Function?
Observe the patient pour a glass of water and then put on a jacket.
85
Shoulder - Look?
1. Any aids or adaptations.
2. Ask patient to remove covering clothing and expose both upper limbs, neck, chest.
3. Scan the patient from top to toe. Inspect from the front, side, behind.
4. Look especially for:
a. Contours
b. Joint swelling
c. Scars
d. Bruising
e. Position of both shoulders looking for dislocation
- -> Remember to inspect the axillary regions.
86
Shoulder - Look - Contours?
Make note of any obvious asymmetry or deformity such as:
1. Winging of the scapula.
2. Prominence of acromioclavicular joint.
3. Wasting of the deltoid or short rotators, which overlie the upper and lower segments of the scapula.
87
Shoulder - Look - Joint swelling?
This is more obvious from the front and may be a clue to:
1. Acute bleeds
2. Rheumatoid effusions
3. Pseudogout
4. Sepsis
88
Shoulder - Look - Evidence of dislocation?
1. Posterior dislocation can be seen when the arm is held in an internally rotated position.
2. Anterior dislocation can be seen easily when the arm is displaced in a forward and downward position.
89
Shoulder feel?
1. Always ask about PAIN before getting started.
2. Make note of any temperature changes, tenderness, or crepitus. Standing in front of the patient:
a. Palpate the soft tissues and bony joints.
b. Check the interscapular area for pain.
c. Palpate the supraclavicular area for LYMPHADENOPATHY.
90
Shoulder - Feel - Palpitation of the soft tissues and bony points in WHAT ORDER?
1. Sternoclavicular joint
2. Clavicle
3. Acromioclavicular joint
4. Acromial process
5. Head of humerus
6. Coracoid process
7. Spine of scapula
8. Greater tuberosity of humerus
91
Shoulder - Move?
1. Remember test passive + active movements at each stage.
2. Quantify movement in degrees (measure).
3. To test true glenohumeral movement, anchor the scapular by pressing firmly down on the top of the shoulder. After about 70 degrees of abduction, the scapula rotates on the thorax - movement is scapulothoracic.
92
Shoulder flexion?
Ask the patient to raise their arms forwards above their head.
93
Shoulder extension?
Straighten the arms backwards as far as possible.
94
Shoulder abduction?
Move the arm away from the side of the body until the fingertips are pointing to the ceiling.
95
Shoulder adduction?
Ask the patient to move the arm inwards towards the opposite side, across the trunk.
96
Shoulder external rotation?
With the elbows held close to the body and flexed to 90 degrees, ask the patient to move the forearms apart in an arc-like motion in order to separate the hands as widely as possible.
97
Shoulder internal rotation?
Ask the patient to bring the hands together again across the body. (Loss of rotation suggests a capsulitis)
98
Shoulder compound movements?
These types of movements may be employed as screening tests to assess shoulder dysfunction, taking the place of a fuller examination if no abnormalities are detected:
1. Ask the patient to put both hands behind the head (external rotation in abduction).
2. Ask the patient to reach up their back with the fingers to touch a spot between their shoulder blades (internal rotation in adduction).
99
Shoulder - Special tests - Testing for a rotator cuff lesion/tendonitis "the painful arc"?
1. Ask the patient to abduct the shoulder against light resistance.
2. Pain in early abduction suggests a rotator cuff lesion and usually occurs between 40-120 degrees.
3. This is due to a damaged and inflamed supraspinatus tendon being compressed against the acromial arch.
100
Shoulder - Special tests - Testing for acromioclavicular arthritis?
If there is pain during a high arc movement (starting at about 90 degrees) and the patient is unable to raise their arm straight up above their head to 180, even passively, this is suggestive of acromioclavicular arthritis.
101
A word about winging of the scapula?
This arises due to weakness of serratus anterior as a result of:
1. Damage to the long thoracic nerve.
2. Injury to the brachial plexus.
3. Injury or viral infections of C5-C7 nerve roots
4. Muscular dystrophy
- -> Becomes obvious only when the serratus anterior contracts against resistance such as pushing outstretched hands against a wall.
102
Spine - Look?
1. Walking aids or wheelchair.
2. Watch how the patient walks into the room or moves around the bed area.
3. Study their posture, paying particular attention to the neck.
4. Ask the patient to strip down to their underwear. Inspect from in front, the side, and behind in both the standing and sitting positions.
103
Spine - Look especially for?
1. Scars
2. Pigmentation
3. Abnormal hair growth
4. Unusual skin creases.
5. Asymmetry including abnormal spinal curvature:
a. Kyphosis --> Convex curvature - normal in the T-spine.
b. Lordosis --> Concave curvature - normal in the L- and C-spines.
c. Scoliosis --> Side-to-side curvature away from the midline.
104
Spine - Look - A question mark spine?
A question mark spine with exaggerated thoracic kyphosis and a loss of lumbar lordosis is classic of ankylosing spondylitis.
105
Spine - Feel?
Palpate each spinous process noting any prominence or step and feel the paraspinal muscles for tenderness.
--> You should also make a point of palpating the sacroiliac joints.
106
Spine - Move - C-spine?
Assess active movements of the cervical-spine first. These include flexion, extension, lateral flexion, and rotation.
It is often helpful to demonstrate these movements yourself.
107
C-spine - Flexion?
Ask the patient to put their chin on their chest.
108
C-spine - Extension?
Ask the patient to look up to the ceiling.
109
C-spine - Lateral flexion?
Ask the patient to lean their head sideways, placing an ear on their shoulder.
110
C-spine - Rotation?
Ask the patient to look over each shoulder.
111
Move T- and L- spine?
Movements at the thoracic and lumbar spin include flexion, extension, lateral flexion, and rotation.
112
T- and L-spine flexion?
Ask the patient to touch their toes.
113
T- and L-spine extension?
Ask the patient to lean backwards.
114
T- and L-spine lateral flexion?
Ask the patient to bend sideways, sliding each hand down their legs as far as possible.
115
T- and L-spine rotation?
Anchor the pelvis (put a hand on either side) and ask the patient to twist at the waist to each side in turn.
116
Spine - Measure - Schober's test?
This is useful measurement of lumbar flexion:
1. Ask the patient to stand erect with normal posture and identify the level of the posterior superior iliac spines on the vertebral column.
2. These are located at L5.
3. Make a small pen mark at the midline 5cm below the 10cm above this point.
4. Now instruct the patient to bend at the waist to full forward flexion.
5. Measure the distance between the 2 marks using a tape measure
6. The distance should have increased to >20cm (an increase of >5cm).
117
Spine - Special tests - Sciatic nerve stretch test?
1. This is used to look for evidence of nerve root irritation.
2. With the patient lying supine, hold the ankle and lift the leg, straight, to 90 degrees.
3. Once there, dorsiflex the foot (Bragard test). If positive, pain will be felt at the back of the thigh. Pain may be relieved by knee flexion.
4. A positive stretch test suggests tension of the nerve roots supplying the sciatic nerve (L5-S2), commonly over prolapsed disc (L4/L5 or L5/S1).
118
Spine - Special tests - Femoral nerve stretch test?
With the patient lying prone, abduct and extend the hip, flex the knee and plantar-flex the foot.
The stretch test is positive if pain is felt in the thigh/inguinal region.
119
Hip - Look?
1. Expose the whole lower limb.
2. Look around the room for any aids or devices such as orthopaedic shoes or walking aids.
3. Ask them to walk and note the gait.
4. Note if there is any evidence of obvious pain.
120
Hip - Look - Especially for?
With the patient in the standing position, inspect from the front, side, and behind:
1. Scars
2. Sinuses
3. Asymmetry of skin creases
4. Swelling
5. Muscle wasting
6. Deformities
121
Hip - Feel?
1. Feel for bony prominences such as the anterior superior iliac spines and greater trochanters.
2. Check that they are in the expected position.
3. Palpate the soft tissue contours and feel for any tenderness in and around the joint.
122
Hip - Move?
1. Ask the patient if they have any pain before examining.
2. Fix the pelvis by using your left hand to stabilize the contralateral anterior superior iliac spine since any limitation of hip movement can easily be hidden by movement of the pelvis.
123
Hip - Move - With the patient SUPINE?
1. Flexion
2. Abduction
3. Adduction
124
Hip - Flexion?
Ask the patient to flex the hip until the knee meets the abdomen - normal is around 120 degrees.
125
Hip abduction?
With the patient's leg held straight, ask them to move it away from the midline, normal is 30-40 degrees.
126
Hip - Adduction?
With the patient's leg held straight, ask them to move it across the midline - Normal is 30 degrees.
127
Hip - Move - With the patient prone?
1. Extension
2. Internal rotation
3. External rotation
128
Hip extension?
Asking the patient to raise each leg off the bed, normal is only a few degrees.
129
Hip internal rotation?
Ask the patient to keep the knees tight together and spreading the ankles as far as possible.
130
Hip external rotation?
Ask the patient to cross the legs over.
131
Hip - Move - Passive movements?
Most should be assessed by the examiner as for active movements while the patient is in a relaxed state.
132
Hip - Passive external and internal rotation?
With the patient supine, flex the knee, stabilizing it with one hand while the other hand moves the heel laterally or medially so that the heel either moves away or towards the midline (internal and external rotation, respectively).
133
Hip - Measure (limb length)?
True shortening, in which there is loss of bone length, must not be confused with apparent shortening due to a deformity at the hip, in which there is no loss of bone length.
134
Hip - Measure technique?
1. With the patient supine, place the pelvis square and the lower limbs in comparable positions in relation to the pelvis.
2. Measure the distance from the anterior superior iliac spine to the medial malleolus on each side (true length).
135
Hip - Apparent length?
Apparent length is measured from a midline structure such as the xiphisternum to the medial malleolus.
136
Hip - Special tests?
1. Trendelenberg test
| 2. Thomas' test
137
Hip - Trendelenberg test?
This is useful as an overall assessment of the function of the hip and will expose dislocations or subluxations, weakness of the abductors, shortening of the femoral neck, or any painful disorder of the hip.
138
Hip - Trendelenberg test - Steps?
1. Ask the patient to stand up straight without any support.
2. Ask them to raise their left leg by bending the knee.
3. Watch the pelvis (should normally rise on the side of the lifted leg).
4. Repeat the test with the patient standing on the left leg.
5. A positive test is when the pelvis falls on the side of the lifted leg indicating hip instability on the supporting side (ie the pelvis falls to the left = right hip weakness).
139
Hip - Thomas' test?
A fixed flexion deformity of the hip (often seen in osteoarthritis) can be hidden when the patient lies supine by tilting the pelvis and arching the back.
The Thomas' test will expose any flexion deformity.
140
Hip - Thomas' test - steps?
1. With the patient lying supine, feel for a lumbar lordosis (palm upwards).
2. With the other hand, flex the opposite hip and knee fully to ensure that the lumbar spine becomes flattened.
3. If a fixed flexion deformity is present the opposite leg flexes too (measure the angle relative to bed).
4. Remember to repeat the test on the other hip.
141
Knee - Look?
1. Scan the room for aids or other clues.
2. Inspect the patient standing.
3. Compare sides.
142
Knee - Look especially for?
1. Deformity (varus, valgus, or flexion)
2. Scars or wounds to suggest infection past or present?
3. Muscle wasting (quadriceps)
4. Swelling (including posteriorly)
5. Erythema
6. Look for loss of the medial and lateral dimples around the knees which suggest the presence of an effusion.
143
Knee - Feel?
1. Always ask about pain before getting started.
| 2. Always compare sides.
144
Knee - Feel - With the patient supine?
1. Palpate for temperature using the back of the hand.
2. Ask if the knee is tender on palpation.
3. Feel around the joint line while asking the patient to bend the knee slightly.
4. Palpate the collateral ligaments (either side of the joint).
5. Feel the patellofemoral joint (by tilting the patella).
145
Knee - Feel - Examining a small effusion - the "bulge" sign?
1. Holding the patella still, empty the medial joint recess using a wiping motion of your index finger --> Will milk any fluid into the lateral joint recess.
2. Now apply a similar wiping motion to the lateral recess and...
3. Watch the medial recess --> If there is any fluid present, a distinct bulge should appear on the flattened, medial face and it is milked out of the lateral side.
146
Knee - Feel - Examining for a large effusion - the "patellar tap"?
1. Move any fluid from the medial and lateral compartments into the retropatellar space.
2. Apply firm pressure over the suprapatellar pouch with the flat of the hand and use your thumb and index finger placed either side of the patella to push any fluid centrally.
3. With the first one or two fingers of the other hand, push the patella down firmly.
4. If fluid is present, the patella will bounce off the lateral femoral condyle behind. You will feel it being pushed down and then "tap" against the femur.
147
Knee - Move?
Remember to test passive + active movements at each stage - Quantify any movement in degrees (measure).
148
Knee - Move - steps?
Begin by moving the joint passively and feel over the knee with one hand for any crepitus.
149
Knee - Move - Flexion?
Ask the patient to maximally flex the knee - Normal 135 degrees.
150
Knee - Move - Extension?
Ask the patient to straighten the leg at the knee.
151
Knee - Move - Hyperextension?
Assess by watching the patient lift the leg off the bed and then, holding the feet stable in both hands above the bed/couch and ask the patient to relax.
Ensure that you are not causing the patient any discomfort.
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Knee - Move - Measure?
The visual impression of wasting of the quadriceps can be confirmed by measuring the circumference of the thighs at the same level using a fixed bony point of reference eg 2.5cm above the tibial tubercle.
153
Knee - Special tests?
1. Testing for medial/lateral collateral ligament instability.
2. Anterior and posterior drawer tests.
3. McMurray's test
4. Apley's test
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Knee - Testing for lateral and medial collateral ligaments - Steps?
1. Take the patient's foot under your right upper arm.
2. Hold the patient's extended knee firmly with both hands.
3. Attempt to bend the distal leg medially (varus) --> Tests lateral collateral ligament.
4. Attempt to bend the distal leg laterally (valgus) --> Tests medial collateral ligament.
5. Repeat the above with the knee at 30degrees dorsiflexion.
- -> Normally, the joint should move no more than a few degrees, excessive movement suggests a torn or stretched collateral ligament.
155
Anterior and posterior drawer tests?
Test anterior/posterior cruciate ligaments.
156
Anterior/Posterior drawer tests - Steps?
1. Ensure the patient is lying in a relaxed supine position.
2. Ask the patient to flex the knee to 90 degrees.
3. You may wish to position yourself perched on the patient's foot to stabilize the leg.
4. Wrap your fingers around the back of the knee using both hands, positioning the thumbs over the patella pointing towards the ceiling.
5. Push up with your index fingers to ensure the hamstrings are relaxed.
6. The upper end of the tibia is then pulled forwards and pushed backwards in a rocking motion.
Normally --> No or very little motion.
Anterior crus. laxity --> Excessive anterior movement.
Posterior crus. laxity --> Excessive posterior movement.
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McMurray test - Steps?
Test for meniscal tears:
1. With the patient lying supine, bend the hip and knee to 90degrees.
2. Grip the heel with your right hand and press on the medial and lateral cartilage with your left hand.
3. Internally rotate the tibia on the femur and slowly extend the knee.
4. Repeat but externally rotate the distal leg while extending the knee.
5. Repeated with varying degrees of knee flexion.
- -> If there is a torn meniscus, a tag of cartilage may become trapped between the articular surfaces, and cause pain and an audible click.
- -> You may also be able to feel the click with your left hand.
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Apley's test - Steps?
Another test for meniscal tears:
1. Position the patient PRONE with the knee flexed to 90.
2. Stabilize the thigh with your left hand.
3. With the right hand, grip the foot.
4. Rotate or twist the foot and press downwards in a "grinding motion".
- -> This test should produce symptoms if a meniscus is torn.
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Ankle and foot - Look?
1. Expose the lower limbs and make note of any walking or other aids present.
2. Take a moment to also examine the shoes carefully for any abnormal wear or stretching.
3. Examine the feet and ankles both when the patient is standing and, more carefully, with the patient lying on a couch or bed.
160
Ankle and foot - Look especially?
1. Skin or soft tissue lesions including calluses, swelling, ulcers and scars.
2. Muscle wasting at the calf and lower leg.
3. Deformities especially involving the arch --> Pes planus, pes cavus.
4. Look for a bunion (bony deformity) at the 1st MTP joint.
5. Look for a bunionette at the 5th MTP joint.
6. Examine the nails carefully for any abnormalities such as fungal infections or in-growing toenails --> Don't forget to look between the toes.
7. Inspect for hammer toes, claw toes or clubbing of the feet (talipes equinovarus).
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Ankle and foot - Feel?
Always ask about pain before getting started:
1. Assess the skin temperature and compare over both feet.
2. Look for areas of tenderness, particularly over bony prominences as well as the metatarsal heads.
3. Squeeze across the MTP joints and assess pain and movement.
4. Remember to Palpate any swelling, edema, or lumps.
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Ankle and foot - Move?
1. The ankle and foot is a series of joints which function as a unit.
2. Remember to test passive + active movements at each stage.
3. Active movements should be performed with the patient's legs hanging over the edge of the bed.
163
Ankle and foot - Move - Ankle Dorsiflexion?
Ask the patient to point their toes at their head.
164
Ankle plantarflexion?
Ask the patient to push the toes down towards the floor "like pushing on a pedal".
165
Ankle inversion?
(Subtalar joint between the talus and calcaneum).
Grasp the ankle with one hand and with the other, grasp the heel, thereby fixing the calcaneum and turn the sole inwards towards the midline.
166
Ankle Eversion?
As inversion but turn the sole outwards, away from the midline.
167
Ankle midtarsal joints?
Grasp the heel with one hand and attempt to move the tarsus up and down and from side to side with the other.
168
Toe flexion?
Ask the patient to curl their toes.
169
Toe extension?
Ask the patient to straighten the toes.
170
Toe abduction?
Ask the patient to fan out their toes as far as possible.
171
Toe adduction?
Ask the patient to hold a piece of paper between their toes.
172
Ankle and foot - Measure?
Calf circumference can be measured bilaterally to check for any discrepancies which may highlight muscle wasting/hypertrophy (10cm below the tibial tuberosities).
173
Ankle and foot - Special tests - Simmond's test?
Used to assess for a ruptured Achilles' tendon.
1. Ask the patient to kneel on a chair with their feet hanging over the edge. Squeezes both calves.
2. Normally the feet should plantarflex. If the Achilles' tendon is ruptured, there will be no movement on the affected side.
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A word on inversion and eversion?
1. Orthopaedic purists will say that the "ankle" cannot invert or evert as it is mainly a simple hinge - the eversion/inversion tests are, therefore, a "failure only" test.
2. You should note that some inversion/eversion is possible in the normal state at the tarsal joints - as tested by neurologists.
3. Orthopaedic practitioners test pathological inversion and eversion by watching the heels from behind as the patient stands on tip-toes.
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Important presenting patterns - RA - Epidemiology?
1. There is a strong association with HLA-DR4 (more severe disease).
2. 1-3% of the population in all racial groups.
3. With peak age of onset in the 4th and 5th decades and a female:male ratio of 3:1.
176
Articular features of RA?
1. RA usually presents as a symmetrical Polyarthritis affecting the wrists and small joints of the hands and feet.
2. Occasionally, patient presents with a MONOarthritis such as the knee and shoulder.
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RA - common presenting symptoms?
1. Joint pain
2. Stiffness
3. Swelling
Typically worse in the mornings and improves as the day progresses.
178
Signs of RA in the hands and wrists?
Synovitis --> Sparing of the DIP joints.
1. Ulnar deviation of fingers (subluxation/dislocation at the MCP joints).
2. Swan neck deformity: hyperextension of PIP joints with flexion of DIP and MCP joints.
3. Boutonnière's deformity: flexion deformity of PIP with extension of DIP and MCP joints.
4. Z deformity of the thumb: flexed MCP joint with extended interphalangeal joint of thumb.
5. Triggering of finger.
6. Generalized wasting of small muscles of hand.
7. Cutaneous vasculitis.
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Signs of RA in the feet?
1. Forefoot synovitis with proximal Phalangeal subluxation dorsally.
2. Metatarsal head erosion and displacement towards the floor
3. Patient feel it "like walking on marbles".
4. Valgus deformities
5. Collapse of longitudinal arch.
180
Sign of RA in the spine?
Atlantoaxial subluxation +/- spinal cord compression.
181
Extra Articular features of RA - rheumatoid nodules?
Common at sites of pressure (elbows and wrists).
| --> associated with more severe disease and always RF (+).
182
RA - Anemia etiology?
1. Anemia of chronic disease
2. GI bleeding associated with NSAID use.
3. Bone marrow suppression secondary to DMARDs such as gold and Penicillamine.
4. Megaloblastic anemia from folate def. (Also secondary to methotrexate) or pernicious anemia.
5. Felty's syndrome --> RA, splenomegaly, and leukopenia.
183
Extra-articular features of RA - Lung features?
1. Pleuritic pain
2. Pleural effusions
3. Pulm. Fibrosis
4. Pulmonary nodules
5. Obliterative bronchiolitis
6. Caplan's syndrome --> Massive lung fibrosis in RA patients with pneumoconiosis.
184
Extra articular features of RA - Neurological features?
1. Peripheral nerve entrapment.
2. Mononeuritis multiplex.
3. Peripheral neuropathy
4. Cervical myelopathy due to atlanto-axial subluxation
185
RA - Cardiac features?
1. Pericarditis
| 2. Pericardial effusions
186
RA - Eye features?
1. Painless episcleritis
2. Painful scleritis
3. Scleromalacia perforans
4. Keratoconjunctivitis sicca
5. Sjögren syndrome
6. Cataracts (chloroquine, steroids)
187
RA - Vasculitis?
1. Nail fold infarcts
2. Cutaneous ulcerations
3. Digital gangrene
4. Cerebral and Mesenteric infarctions
5. Coronary and renal vasculitis (rare)
188
RA - Skin lesions?
1. Palmar erythema
2. Pyoderma gangrenosum
3. Amyloidosis --> Proteinuria, HSM
4. Systemic features --> Fever, malaise, weight loss, lymphadenopathy.
189
Osteoarthritis - General features?
1. Chronic disorder of synovial joints characterized by focal cartilage loss and an accompanying reparative bone response.
2. It represents the SINGLE MOST IMPORTANT CAUSE of locomotor disability with a prevalence which increases with age + a female preponderance.
190
Osteoarthritis - Joints most commonly affected?
1. Hips
2. Knees
3. Spine
4. 1st carpometacarpal
5. 1st metatarsal
6. DIP joints
191
Osteoarthritis - Secondary causes?
1. Trauma
2. RA
3. Infection
4. Neuropathic (Charcot's) joints
5. Metabolic (Paget, Acromegaly, hemochromatosis, avascular necrosis, hypoparathyroidism).
192
Osteoarthritis - Clinical features - Common symptoms include?
1. Swelling
2. Deformity
3. Stiffness
4. Weakness
5. Pain normally worse after activity and relieved by rest.
193
Osteoarthritis - Common signs?
1. Hard bony swellings of the DIP joints (Heberden nodes)
2. Bony nodules at the PIP joints (Bouchard nodes)
3. "Square hand deformity" due to subluxation of the base of the thumb.
4. Valgus, varus deformities
5. Crepitus
6. Wasting and weakness (especially of the quadriceps and glutei)
7. Tilting of the pelvis.
194
Crystal arthropathies - Gout?
A disorder of purine metabolism.
1. Characterized by Hyperuricemia due to either overproduction or underexcretion of uric acid.
2. Prolonged hyperuricemia leads to the formation of urate crystals in the synovium, other connective tissues and the kidney.
195
Clinical features of acute gout?
1. Severe pain and swelling classically in the great toe MTP joint - worse at night and associated redness.
2. Occasionally multiple joints are involved.
3. +/- systemic symptoms.
196
Clinical features of chronic (tophaceous) gout?
Tophus formation - Soft tissue deposits of Urate found especially in digits, helix of the ear, bursae and tendon sheaths.
+/- overlying necrotic skin with chalky exudate of urate crystals.
197
Pseudogout - Overview?
Caused by deposition of calcium pyrophosphate crystals in the synovium, joint capsule, and tendons.
198
MCC of an acute Monoarthritis in the elderly?
Pseudogout - May present as either an acute synovitis or as a chronic arthritis.
199
Pseudogout - Linked to?
Chondrocalcinosis:
On exam, you may find a swollen, erythematous, tender joint (often knees, wrist, elbow, ankle, or shoulder and MCP joints especially the index and middle) associated with systemic upset.
200
Hyperuricemia - Some causes of?
1. Drugs
2. Chronic renal failure
3. Myeloproliferative and lymphoproliferative disorders (incr. Purine metabolism).
4. Obesity
5. HTN
6. Hypo/Hyperthyroidism
7. Familial
8. Excessive dietary purines
More common in the summer months due to reduced fluid intake and increased fluid loss.
201
Conditions associated with gout?
1. Obesity
2. Type IV hyperlipidemia
3. HTN
4. Impaired glucose tolerance
5. IHD
202
Spondyloarthropathies - examples?
1. Ankylosing spondylitis
2. Psoriatic arthritis
3. Reactive arthritis
4. Enteropathic arthritis
203
Spondyloarthropathies - General features?
1. Characteristically lack the rheumatoid factor.
2. Associated with HLA-B27.
3. Present at any age, though YOUNG MALES are primarily affected.
204
Spondyloarthropathies - Key features?
1. Enthesitis (an enthesis is the insertion of a tendon, ligament or capsule into a bone).
2. Synovitis
3. Sacroiliitis
4. Dactylitis
5. Peripheral arthritis predominantly affecting the large joints.
205
Ankylosing spondylitis - General features?
Usually develops in early adulthood with a peak age of onset in the mid 20s and is 3 times more common in males.
206
Ankylosing spondylitis - Common symptoms?
1. Lower back pain and stiffness which is typically worse in the morning and after long periods of rest.
2. Chest pain as a result of T spine involvement as well as enthesis at the costochondral joints.
3. Tender sacro-iliac joints.
4. Pain in peripheral joints such as the shoulders and knees.
207
Ankylosing spondylitis - Musculoskeletal features/signs?
1. Question mark posture (loss of lumbar lordosis, fixed Kyphoscoliosis of the T spine, compensatory extension of the C spine).
2. Protuberant abdomen.
3. Schober's test positive
4. Achilles Tendonitis
5. Plantar fasciitis
208
Ankylosing spondylitis - Some extra skeletal features?
1. Anterior uveitis
2. Aortic regurgitation
3. Apical lung fibrosis
4. AV block
5. Amyloidosis (secondary)
6. Atlantoaxial dislocation
7. Traumatic fracture of a rigid spine
8. Hypoxia
9. Fever
10. Weight loss
209
Psoriatic arthritis - General features?
Affects up to 10% of patients with psoriasis and may precede or follow the skin disease.
--> Arthropathy does NOT correlate with the severity of the skin lesions.
210
Psoriatic arthritis - Subtypes?
5 main subtypes:
1. Asymmetrical DIP joint arthropathy.
2. Asymmetrical large joint mono- or oligoarthropathy.
3. Spondyloarthropathy and Sacroiliitis.
4. Rheumatoid-like hands (identical to RA but Seronegative).
5. Arthritis mutilans (severely destructive form with telescoping of the fingers).
211
Psoriatic arthritis - Associated clinical features?
1. Psoriatic plaques - classically found on the extensor surfaces, scalp, behind the ears, in the navel and natal cleft.
2. Nail involvement - pitting, Onycholysis, discoloration, thickening.
3. Dactylitis - sausage-shaped swelling of the digits due to tenosynovitis.
212
Reactive arthritis - General features?
An aseptic arthritis, strongly linked to a recognized episode of infection.
Common causes are gut and Genitourinary infections.
213
Reactive arthritis - Presentation?
1. Usually in young adults.
2. Presents with an asymmetric and oligoarticular arthritis with symptoms starting a few days to a few weeks after the infection.
3. Enthesitis and dactylitis are other common features and patients may experience pain in the articular joints.
214
Reactive arthritis - Associated extra skeletal features?
1. Urethritis
2. Conjunctivitis
3. Skin and mucosal lesions
215
Reactive arthritis - Reiter syndrome?
A form of reactive arthritis associated with a classic triad of:
1. Arthritis
2. Urethritis
3. Conjunctivitis
216
Reactive arthritis - Often preceded by?
Dysenteriae infections such as shigella, salmonella, campylobacter, Yersinia, or infections of the genital tract.
217
Reactive arthritis - Other findings?
1. Mouth ulceration
2. Circinate balanitis
3. Keratoderma
4. Blennorrhagica (pustular-like lesions found on the palms or soles) and persistent plantar fasciitis.
218
Enteropathic arthritis?
Is a peripheral or axial arthritis occurring in association with IBD and does NOT typically correlate with the severity of bowel disease.
--> The peripheral arthritis has been shown to improve if the affected bowel is resected.
219
Osteoporosis - Types?
Type I --> accelerated (mainly trabecular) bone loss secondary to estrogen deficiency --> leads to fractures of vertebral bodies as well as the distal forearm in women in their late 60s and 70s.
Type II --> Age-related cortical and Trabecular bone loss occuring in BOTH sexes --> leads to fractures of the proximal femur in the elderly.
220
Osteoporosis - Clinical features?
Features differ according to the fracture site:
1. Marked kyphosis
2. Loss of height
3. Protuberant abdomen
4. Spinal tenderness
221
2nd MC disease of the bone after osteoporosis?
Paget --> more common in males + affecting 3% of the population >40yrs.
222
Paget - Important clinical features and complications?
1. Enlargement of the skull.
2. Hearing loss (ossicles are involved and VIII nerve compression)
3. Optic atrophy angioid streaks
4. Cardiac failure
5. Kyphosis, anterior bowing of the tibia, lateral bowing of the femur.
6. Increased bone warmth.
7. Decr. Mobility
8. Fractures
9. Sarcomatous change (rare)
10. Cold compression
11. Cerebellar signs
12. Hypercalcemia
223
Risk factors for osteoporosis?
1. Smoking
2. Alcohol consumption
3. BMI <19
4. FHx
5. Premature menopause
6. Prolonged immobilization
7. Prolonged secondary amenorrhea
8. Primary hypogonadism
9. Low dietary calcium and vitamins
10. Older age
11. Female gender
12. Sedentary lifestyle
13. Caucasian or Asian origin
14. Chronic disorders
224
Chronic disorders that lead to osteoporosis?
1. Anorexia nervosa
2. Malabsorption syndromes
3. Primary hyperthyroidism
4. Post transplantation
5. Cushing
6. Chronic renal failure
225
Some important causes of a swollen knee?
1. RA
2. Ruptured Baker's cyst
3. Pseudogout
4. Gout
5. Edematous states (eg CCF, nephrotic syndrome)
6. Trauma
7. Charcot's knee
8. Septic arthritis
9. Hemarthrosis
226
Types of joints?
Classified according to the material uniting the articulating bones as well as the degree of movement they allow:
1. Fibrous joints
2. Cartilagenous joints
3. Synovial joints
