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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