1
Q
Types of Synovial Joints
A
- Ball and socket – allows multiaxial movement e.g. hip, shoulder; one rounded surface articulating in a “cup”
- Condyloid – biaxial movement e.g. CMJ, carpometacarpal, temporo-mandibular; wrist
- Saddle – biaxial movement e.g. CMJ of thumb, wrist
- Note: Carpometacarpal Joint (CMJ) -> mostly Saddle joint
- Hinge – allows uniaxial movement (movement in one plane) e.g. elbow, knee (complex hinge), IP joints
- Pivot - uniaxial e.g. atlantoaxial , proximal radio-ulnar. Usually with a rotatory component Gliding – allows uniaxial movement e.g. patello-femoral
- Gliding – allow uniaxial movement
2
Q
Joint pain DDx
A
- Pain came on suddenly, minutes? – fracture.
- 0ver several hours or 1-2 days? –infectious, crystals deposition, inflammatory arthropathy.
- Sudden onset andrapidincreaseinseverity-gout
- History of IV drug abuse or a recent infection? –
- septic joint.
- Recurring similar attacks? – crystals or inflammatory arthritis.
- Prolongedcoursesofsteroids?–infectionor osteonecrosis of the bone.
3
Q
Symptoms outside of Joints (extra articular)
A
- Constitutional - malaise, fatigue – inflammatory arthritis e.g. RA, Psoriatic, SLE; fever e.g. septic arthritis , gout (low-grade fever )
- Skin Rash e.g. Psoriatic, SLE(often photosensitive) Rheumatic fever, Juvenile RA
- Eye symptoms e.g. Reiter’s(redness, pain), Sjogren’s (grittiness, stickiness)
- Nodules – tophi of gout
- Muco-cutaneous ulcers
- Decrease chest expansion – decrease in ankylosing spondylitis
- CNS – neuropathy
- Heart – murmurs, pleural effusion (SLE, RA)
4
Q
Special tests – hip and spine
A
Thomas – for fixed flexion contracture of hip joint (patient lies supine on the examination table and brings one knee in direction to the chest/ flexes hip, while the other leg remains extended).
Sacroiliac stress – for sacroilitis
Straight leg raising and bowstring – for sciatica. Please also perform neurologic testing for evidence of nerve compression
5
Q
Gout vs pseudogout
A
- PseudoGout -> large joints
- Gout -> smaller joints mostly
6
Q
No crystals in joint aspirate
A
- Rheumatoid Arthritis, Psoriatic arthritis,
- Seronegative Spondyloarthropathies e.g. Ankylosing spondilitis.
- SLE
- Acute Rheumatic Fever(ARF)
7
Q
Monoarticular - Septic Joint
A
- Mostarticularsepticinfectionsaffectasingle joint
- 15-20% cases polyarticular
- Most common sites: knee, hip, shoulder
- Most patients are febrile but about 20% of patients are afebrile
- Joint pain is moderate to severe
- Joints visibly swollen, warm, often red
- Associated illness: RA, DM, SLE, cancer, etc
8
Q
Acute Polyarthritis
A
Infection
- Gonococcal
- Meningococcal
- Lyme disease
- Rheumaticfever
- Bacterialendocarditis
- Viral (rubella, parvovirus, Hep. B)
Inflammatory
- RA
- JRA
- SLE
- Reactive arthritis
- Psoriatic arthritis
- Polyarticular gout
- Sarcoid arthritis
9
Q
Temporal Patterns in Polyarthritis
A
- Migratory pattern: Rheumatic fever, gonococcal (disseminated gonococcemia), early phase of Lyme disease
- Additive pattern: RA, SLE, psoriasis
- Intermittent: Gout, reactive arthritis
10
Q
Sacroilitis
A
- Sacroiliac stress test: applies rotational force to the SI joints with pain felt in the joint(s).
- Sacroilitis occurs in > 90% of patients with ankylosing spondylitis(HLA B27-related, typically in young men). Symptoms include low back pain and stiffness, with slowly progressive immobility of the spinal joints
11
Q
Rheumatoid arthritis
A
- earlymorningstiffness
- lasts longer(than osteoarthritis)
- gets worse after rest
- gets a little better after exercise
- never goes away
- affects multiple joints
12
Q
Osteoarthritis
A
- symptoms worse late afternoon
- lasts for 5-10min
- gets better after rest
- exercise worsens symptoms
- partly due to wear&tear; comes early in life
- single joint
13
Q
OBSERVE
A
- Note abnormalities of gait
- antalgic gait–rapid transfer of weight from 1 foot to other on 1 side;patient will slouch
- limping
- Tophi – on helix, antihelix, or elbows; indicate gout
- Rheumatoid nodules – hard & non-tender; on extensor surface of the forearms
- Heberden’s nodes – on distal interphalangeal joints of fingers; (osteoarthritis)
- Bouchard’s nodes – on proximal interphalangeal joints of fingers; (osteoarthritis)
- Psoriasis (scaly rash) – on extensor surface of elbows or knees, scalp & nails
- eye inflammation – indicates uveitis
- Reiter’s Syndrome: uveitis + arthritis
14
Q
Special tests for carpal tunnel syndrome
A
- Injury to median n.
- Affects lateral 3 fingers & thenar eminence
- Phalen’s test: Ask patient to place dorsum of both hands together and fully flex both wrists.
- Tinel’s test: Percuss over anterior surface of wrist at level of most distal skin crease.
15
Q
Special tests: Knee joint effusions
A
Bulge sign (when there is minimal fluid)
- with left hand, compress suprapatellar pouch
- compress medial side of joint upwards to displace excess fluid to lateral side of knee (“milk it”)
- then press lateral side & observe bulge caused by fluid returning to medial side
Ballotment sign (when there is a lot of fluid -> don’t have to“milk it”)
- with left hand, compress suprapatellar pouch (ensure thumb & index finger are firmly surrounding upper border of patella)
- with index & middle finger of right hand, push patella firmly backwards
- if excess fluid is present, patella will push slowly through fluid & collide w/ femur as palpable tap
16
Q
Special tests at hip
A
Lasegue’s or straight leg raising test
- with patient lying supine, raise each foot passively to ~60°
- pain in lumbar spine or down lower limb or both -> sciatic nerve root irritation
Bowstring maneuver
- lower foot until pain is just relieved, then dorsiflex foot
- will again cause pain if sciatic nerve root irritation is present
17
Q
Special tests for tenderness of sacroiliac joint
A
- patient lies supine very close to edge of couch (but sure patient does not fall)
- ask pt. to fully flex distal knee & hip and hold knee tightly to abdominal wall
- slide nearer leg off couch & push firmly down on thigh
- if either joint is inflamed
CPD F2014
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Decks in class (15)
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