Download Rheumatology Physical Examination

Rheumatology Evaluation
Joints are discontinuities in skeleton that permit mobility
• Types of Joints:
– Fibrous tissue or syndesmosis – no motion; skull sutures, interosseus membrane
between radius and ulna
– Cartilage tissue or synchondrosis – some movement ; symphysis pubis or
intervertebral joints
– Hyaline Cartilage or diarthroses – significant movement; knee/elbow
syndesmosis
synchondrosis
Joint components
Synovium
• Covers all intra-articular surfaces except articulating areas of cartilage
• Synovial membrane are special fibroblasts that secrete viscous ultrafiltrate and also have
macrophage functions
– Synovial fluid used for lubrication and nutrition
knee
Bursae
• Fluid filled sacs that facilitate movement
• Lining is similar to synovial lining
– Subcutaneous – forms after birth due to external friction (olecranon and patella)
– Deep – forms before birth due to movement between muscles and bones
(subacromial)
– Adventitious - forms in response to abnormal shearing stresses; not always
present
shoulder
Muscles
Bone
Cartilage
• Precursor to bone
• At the ends of bone
Connections:
TENDONS connections between muscle and bone; are active drivers
ENTHESES site of insertion into the periosteum
LIGAMENTS connections between bones and bones; passive restraints
Definitions:
Arthralgia: joint pain without abnormality
Arthritis (Synovitis): Objective joint abnormality
- Either joint swelling or pain/tenderness with limitation
“-itis” – inflammation of
• Bursitis – bursae inflammation
• Myositis –muscle inflammation
• Enthesitis – insertion site inflammation
• Tenosynovitis – tendon sheath inflammation
• Tendinitis –tendon inflammation
“-opathy” – disease of
• Myopathy, Enthesopathy
Oligoarticular/Pauci-articular – arthritis affecting 2-4 joints or small groups (i.e. wrist)
Polyarticular – arthritis affecting >4 joints
History and Review of Systems
Joint Evaluation
• Pain – site, radiation, quality, usage, at rest
• Night pain –JIA usually does not wake up patient
• Gelling – stiffness after immobility (due to altered joint viscosity) – shortens as
inflammation improves
• Swelling, enthesitis
• Disability- limitation in range of motion
Extra-articular Evaluation
 General: fatigue, weight loss, headache, appetite, fevers, recent illnesses, LAD
 Skin: psoriasis, nail pits, nodules, livedo reticularis, photosensitivity, rash, petechiae, hair
loss, ulcers, Raynaud’s phenomenon, capillary loops
 HEENT: oral ulcers, palatal ulcers, nasal ulcers, dry mouth, dry eyes, cataracts, uveitis
 CV/Pulm: chest pain, SOB, cough, palpitations, exercise intolerance, and h/o pericarditis
 GI: dysphagia, abdominal pain, nausea, vomiting, diarrhea, constipation, anorexia
 GU: dysuria, hematuria, menorrhagia, and dysmenorrhea
 Neuro: weakness, numbness, seizures, sleep problems, depression, headache, chorea
 Psych: CNS changes, depression, memory loss, anxiety
Physical Examination
Joint Evaluation
 Inspection at rest and during movement and palpation
 Positioning of the joint (with pain placed in minimal pressure position)
 Deformity correctable or non-correctable (swan neck)
 Skin changes – including erythema
 Warmth – signs of inflammation
 Swelling:
o Bulge sign – confined space with small fluid volume
o Balloon sign – pressure on one side makes a ballooning of other side
 Tenderness – diffuse, point, and along the joint line
Gait
•
•
Different phases: stance and swing
Different gaits:
o Trendelenburg
o Antalgic
o high stepping/foot drop
o scissors gait/spastic diplegia
Lumbar spine flexibility (Schober’s test)- inspection from behind
Inspect from side of patient:
• Loss of normal cervical and lumbar lordosis
• Facial profile
• Knee deformity
• Lumbar spine flexibility
Inspect from front of patient:
 Swelling over skin changes over sternoclavicular and acromioclavicular joint site
 Equal shoulder height
 Muscle asymmetry
 Knee and foot deformities
 Extend elbows
Test Range of Motioin
 Laterally flex neck and forward flex neck
 Open jaw – TMJ involvement (patient should be able to place 3 of their own fingers
vertically between upper and lower teeth)
 Place both hands behind the head with elbows back
 Place both hands out in front, palms down, fingers straight, elbows 90 degrees; then turn
hands over
 Tight fist
Joint
Primary
movement
Secondary
movement
Tertiary
movement
Wrist
Flexion and
Extension equally
Elbow
Flexion
Extension
Rotations
Shoulder
Abduction
External rotation
Internal rotation
Neck
All movements
equally except
flexion
Thoracic
spine
Extension
Lateral flexion
and rotation
Lumbar
spine
Lateral flexion
Flexion
Hips
Flexion and Internal
Abduction
Rotation equally
Knee
Flexion
Extension
Ankle
Plantar flexion
Dorsiflexion
Subtalar
Varus
Valgus
Extension
Palpate for Swelling/ Synovitis
 Squeeze across 2-5th metacarpals and metatarsal (squeeze)
 Precision pinch
 Thomas sign – indicator of sacroiliac pain (ankle on knee position)
 Press down on patella for balloon sign
Specific Joints
ELBOW
 Lateral epicondyle at insertion of common extensor tendon
 Olecranon bursa
 Lateral joint line between humerus and proximal ulna for synovial swelling or effusion
WRIST
 Support wrist in 15-degree flexion
 Palpate radiocarpal joint and ulnocarpal joint
 Keep extensor tendons relaxed
MCP
 Support palm of hand
 Palpate both sides of the joint line with thumbs
FINGERS
 Palpate both lateral joint lines with thumb and index finger while palpating volar and palmar
sides with opposite thumb and finger
HIP
Femoral-acetabular joint
Trochanteric bursa
KNEE
 Palpate synovial reflection at inferomedial and inferolateral margins of patella
ANKLE
 For tibiotalar joint, palpate 1 cm anterior to distal medial malleolus just medial to extensor
tendon and palpate anterior to distal fibula
Physical Examination- general, extra-articular
Livedo reticularis
 Appears in a broad- based interrupted pattern in systemic vasculitis, including SLE
 May occur as a fine, connected, lacy pattern in normals
Mouth Ulcers
 Ulcerative colitis
 Regional enteritis (Crohn’s disease)
 ? Whipple’s
 ? Behçet’s
Periungual changes
 Seen in lupus erythematosus, dermatomyositis, and scleroderma
 Thickening of capillary loops
 Dropout of capillary
loops
 Hemorrhage in the nail fold may also be present
Saddle nose deformity
 Relapsing polychondritis
 May also occur in Wegener’s granulomatosis and syphilis