Physical Assessment in Rheumatoid Arthritis Flashcards
Active joint count is a measure of INFLAMMATORY ACTIVITY
3 Criteria for an active joint:
1) Effusion
2) Joint tenderness
3) Stress pain
Always SEQUENTIALLY assessed, as they progressively ↑ the level of stress imposed on the joint capsule
Joint Assessment Adult
Active joint count is a measure of __________ ___________
Inflammatory Activity
Presence of joint swelling
OR
Limitation of motion w/ heat, plus over-pressure pain OR joint line tenderness
Joint Assessment Children
S: Swelling
- If synovial effusion is present, STOP. Mark joint as active & do not test further
T: Tenderness
- If joint line tenderness is present, STOP. Mark joint as active & do not test further
OP: Over-Pressure
- If tests for swelling & tenderness are negative, proceed to over-pressure.
When in doubt, record as INACTIVE
STOP Method
Fluid that is confined by the joint capsule but freely mobile within that space
Fluctuation of fluid is detectable along the joint margins
- 2 thumb technique
- 4 finger technique
- Bulge sign
Fatty tissue deposited about the joint may mimic an effusion
- Fat: Soft but fixated in location and is outside the joint capsule
- Effusion: fluctuation in ALL planes
Bony enlargement & joint deformities do not constitute joint swelling
Effusion
Soft but fixed in location & is OUTSIDE joint capsule
- May mimic an effusion
Fat
Knee: The pouch of synovium, medial to patella, is emptied of fluid w/ an upward stroke & refilled w/ a downward stroke on the lateral side
Elbow: Over the radial head when elbow is moved from 45° flexion to full extension
Bulge Sign
Apply pressure over joint line, or the collateral ligaments at the joint line
Firm pressure with enough force to blanch the examiner’s fingernails
For pt’s w/ pain syndromes, compare the pain from pressure on the joint line to an equal amount of pressure on an adjacent bone or soft tissue. For the joint to be classified as active, the former must be greater.
- Easy to get a false positive
Joint Tenderness
Stretching of the inflamed joint capsule
Apply gentle over-pressure when the joint is at the limit of its passive range
Stress Pain
The # of damaged joints is related to the duration of DISEASE & IS AGGRESSIVENESS
Angular deformities
- Deforming force
- Damage to a supporting structure
The definition of damaged joint is controversial
Assessment of Destruction & Deformity
Often involved but usually later in disease
- bony erosion of mandibular condyle & joint space narrowing
- end-stage disease may result in fusion in open bite
Ax: Joint Count ROM - open/close (normal 35-50mm) - lateral deviation (normal 10-15mm) - protrusion (normal 3-6mm) - capsular pattern Palpation - crepitus, clicking, locking
TMJ
Changes:
- Synovitis
- Thinning of RC -> rupture
- Humeral head migrates superiorly
- Impingement of bursae, tendons
- AC joint damage
Shoulder
Changes:
- Synovitis; bulges out into the para-olecrannon fossa
- Loss of extension -> flexion deformity
- Superior radioulnar joint commonly involved -> erosion of radial head
- Bursa inflamed
- Rheumatoid nodules
Elbow
Special tests for common pathologies in RA:
- Wrist DRUJ: Piano Key Sign (test for DRUJ instability)
- MCP: Radial collateral ligament test
0 Hand Intrinsics: Bunnel-Littler
Wrist & Hand
Tests:
- soft tissue & ligamentous support for the DRUJ and unlar carpus
- TFCC or articular disc
- Volar/dorsal radio-ulnar ligaments
- Ulnocarpal ligaments
- ECU sheath
- LT interosseous ligament
1) Forearm in neutral rotation
2) Stabilize distal radius with one hand, apply force to move distal ulna dorsal + volar
Positive: Excessive ulnar movement/subluxation/pain/tenderness
Piano Key Test/Sign
