Download World of Joints: A Look at the Joint Examination

World of Joints
A look at the joint examination
Pediatric Rheumatology
Red Team Resident
Teaching Series
Joint - Definition
• Joints are discontinuities in
skeleton that permit mobility
Diarthrotic Joint Components
• Hyaline Cartilage or
Diarthroses – joints
that allow significant
movement;
– ex: knee/ elbow
• Synovium
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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
Diarthrotic Joint Components
• Muscles
• Bone
• Cartilage
– Precursor to bone
– At the ends of bone
Joint Components
• Tendons
• Ligaments
• Entheses
• connections between
muscle and bone; are
active drivers
• site of insertion into
the periosteum
• connections between
bones and bones;
passive restraints
Joint Terminology
• Arthralgia: joint pain without abnormality
• Arthritis (Synovitis): Objective joint abnormality
– Either joint swelling, or pain/tenderness with limitation
Arthritis: History
• Objective symptoms lasting minimum of 3
days in same joints
• Pain is usually insidious onset but can be
significant enough to affect daily activities
• Morning stiffness – due to gelling
phenomenon very common
• Night pain not common
• Can have accompanying constitutional
symptoms
• Inflammatory vs. mechanical joint pain
Arthritis: History
• Pain characterization
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Site
Number of joints involved
Severity
Frequency
Duration
Pattern of pain
Exacerbating and alleviating factors
Onset: acute or insidious
At rest?
Radiation
Swelling?
Warmth?
Discoloration?
Stiffness?
Arthritis: History
• Pain characterization
– Frequency, Duration, Pattern of pain:
• Persistent- JIA, infection, malignancy
• Intermittent- associated with activity, more likely due to
mechanical problem.
• Migratory pain- last for several days, then resolves,
while other previously unaffected joints become painful.
Characteristic of ARF, PSRA, HSP, leukemia/
lymphoma
• Recurrent-with spontaneous resolution, may indicate
Lyme arthritis, FMF or other periodic syndromes
Arthritis: History
• Pain characterization
– Time of day
• Diurnal variation: JIA is worse in the morning, trauma
or mechanical pain worsens with activity, growing pains
usually at night, malignancy pain day or night
– Rapid onset within 1-2 days: infection, vasculitis
(HSP)
– Insidious onset: JIA
– Inflammatory (red, warm, swollen) or mechanical
pain (locks, gives way)
Arthritis: History
• Pain characterization
– Exacerbating factors: inactivity (gelling phenomenon)
in JIA, physical activity worsens mechanical joint pain
and growing pains
– Alleviating factors: physical activity usually helps in
JIA
• Precipitating factors:
– Trauma
– Antecedent infection
• Disability
Physical Exam - Joints
• 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
Physical Exam - Arthritis
• Swelling: Bulge sign – confined space
with small fluid volume
Balloon sign – pressure on one side
makes a ballooning of other side
•Tenderness – diffuse, point, and along the
joint line
Physical Exam
• 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
Physical Exam
• Inspect from side of patient:
– Loss of normal cervical and lumbar
lordosis
– Facial profile
– Knee deformity
– Lumbar spine flexibility
Physical Exam
• Inspect from behind the patient:
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Straight spine
Similar level of iliac crests
Normal muscle bulk/symmetry
Popliteal swelling
Achilles tendon swelling
Hindfoot deformity
Lumbar spine flexibility (Schoeber’s test)
Back evaluation
Back pain: SI pain
• FABERE test reproduces pain at the
affected SI joint
Back pain: SI pain
• FABERE test reproduces pain at the
affected SI joint
The FABERE test (Patrick test or
"figure of four" test) consists of Flexion
of the hip and knee, with ABduction
and External Rotation at the hip, so
that the ankle of one leg is on top of
the opposite knee (a figure four
configuration). Force is applied
downwards on the bent knee and the
opposite hip, causing Extension at the
sacroiliac joint.
Physical Exam - Gait
• Different phases: stance and swing
• Different gaits:
• Trendelenburg
• Antalgic
• high stepping/foot drop
• scissors gait/spastic diplegia
Arthritis: Knee Exam
Knee Ranging
Muscle bulk and leg length evaluations
Arthritis: Clinical Evaluation
• Affected joints can grow faster causing leg length
discrepancies
Leg lengths – anterior superior iliac spine to medial malleolus
Arthritis: Hip Exam
Hip Ranging
Arthritis: Ankle Exam
Entheses
Entheses
Arthritis: Clinical Evaluation
• Local and general
growth delay seen
– Jaw
– MCP/MTP
Extra-articular Manifestations
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Skin Rashes
Nailfold Capillaries
Eyes
Muscles
Manual Muscle Testing
• Muscle – bulk and strength; wasting of
muscles
– Grading:
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0-no contraction
1-visible contraction w/o movement
2-motion only with gravity eliminated
3-motion against gravity only
4-against gravity and some applied load
5-normal against significant load
• Used for dermatomyositis evaluation
Normal Nailfolds
UVEITIS with synechiae
Band Keratopathy
Reactive arthritis: conjunctivitis
Iritis