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JOINTS Flashcards

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1
Q

Synarthrosis

A

• Fibrous, permits little or no mobility (eg The Skull)

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2
Q

AMPHIARTHROSIS:

A

cartilaginous joints, permits slight mobility (eg.

Vertebrae)

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3
Q

DIARTHROSIS:

A
  • synovial joints (all diarthrosis)
  • permits a variety of movements.
  • (eg. Shoulder, Hip, Elbow, Knee etc)
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4
Q

OLIGOARTICULAR involvement

A

2- 4 joints groups affected
 located dominantly at distal joints
 generally asymmetrical

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5
Q

POLIARTICULAR involvement

A 
> 5 joints affected
 symmetrical /asymmetrical
 dominant at upper or lower limbs
 periarticular involvement associated
 ± systemic involvement associated
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6
Q

Symptoms description

A 
1. Symptoms description
Severity of symptoms
Sequence of symptoms
Patterns of
> Progression
 > Exacerbation
> Remission
  1. Functional impact of the disease
  2. Effects of therapy (current / previous) on the illness course
  3. Compliance to therapy assessment
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7
Q

Symptoms

A
  1. Pain
  2. Stiffness
  3. Limitation of Motion
  4. Swelling
  5. Weakness
  6. Fatigue
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8
Q

1.Pain

A

most common complaint
Definition:
=subjective sensation that is difficult to define,
explain, or measure.
Localization → anatomical description
• ask the patient to point the area with a finger

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9
Q

1.Pain

A

• between joints may suggest
• more accurately if localized in
• small joints of the hands or feet > pain in larger jnt
(shoulder, hip, or spine)

• Superficial tissues
• less focal if arising from deeper structures
• if diffuse, variable, poorly described, or unrelated to
anatomic structures →
- Malingering, or
- Psychological problems
- Fibromyalgia

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10
Q

1.Pain- Characteristics (description)

A
  1. Intensity :variable
    - Intense (↑”aching”) in a joint area suggests an
    inflammatory disorder (arthritis)
    - Sharp or “burning” (suggests neuropathy due to a
    compression, eg. carpal tunnel syndrome)
  2. Severity of pain: mild / moderate / severe
     scale from 1 to 10 (determined by the patient)
    !! If excessive, unbearable, in a patient who can otherwise perform usual activities is rather emotionally amplified
  3. Duration: variable (the patient is asked when it appeared, if it was continuous or had periods of activity alternating with periods of remission)
  4. Type of onset: sudden/ insidious
    Time of onset: the time of day when the pain begins / intensifies)
    → eg. nocturnal pain in gout (microcrystalline arthritis)
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11
Q

Durerea articulara- Caracteristici

A

Location
- ! Localized - joint pain is generally localized (felt
articular / periarticular)

or Iradiated (ex. A pain in the hip may cause also pain at the knee level on the same side)
 Monoarticular/ Poliarticular
 Symmetrical/ Asymmetrical
Example:
- symmetrical rheumatoid syndrome in rheumatoid arthritis
- asymmetric rheumatoid syndrome in reactive arthritis
Irradiate
 distal: nerve compression syndromes (tunnel / compartment
syndrome)
 referred pain

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12
Q

Pain assessment during activity/rest

A

inflammatory process→ Joint pain
• at Rest and

• with Movement (Activity)
- mechanical disorder (degenerative)
• Pain mainly during Activity

Persistence
- at the level of a certain joint or
- migratory character (moves from one joint
to another)

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13
Q

Stiffness

A
  • discomfort perceived by the patient attempting
    to move joints after a period of inactivity

Character
• develops after several hours of inactivity
• may resolve within a few minutes (Mild stiffness)
• may persist for many hours (RA or polymyalgia rheum.)
• usually transient

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14
Q

Morning stiffness

A

Inflammatory disease
- prodromal symptom of rheumatoid arthritis (RA)
- criterion for the diagnosis of RA (absence does not exclude)
NonInflammatory joint diseases
- short duration almost always (usually < 30 min)
- less severe than stiffness
- related to the extent of joint overuse (mechanical or
degenerative joint disease)
- resolve usually within a few days to limitation of the use of the affected joint

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15
Q

Limitation of Motion

A

Fixed
 NOT transient
 Does not vary

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16
Q

Limitation of Motion : important to detect

A

Type of onset
 Abrupt = suggestive of a mechanical problem (tendon rupture)
 Gradual = more common with inflammatory joint disease
The extent of limitation
 Degree of Active and Passive motion limitation

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17
Q

Swelling

A

Determine:
• Where and When occurs
 Information about
1. Factors that influence it
2. Onset and Persistence of the swelling
acutely developed →swelling is most painful
slowly developed is often much more tolerable
! Obese may interpret as swelling collections of adipose tissue over the elbow, knee, ankle

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18
Q

Weakness

A
  • Loss of motor power or muscle strength
  • Objectively demonstrable on physical examination
    Assessment:
    1.Distribution (distal / proximal)
    2.Duration of weakness
    3.Specific patterns
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19
Q

Patterns of weakness

A

musculoskeletal disorders
= Persistent > intermittent
 neuromuscular disorders (myasthenia gravis)
= Initially good strength with subsequent weakness
 inflammatory myopathies
= Weakness occurs in a Proximal distribution
(i.e., shoulders and hips rather than hands and feet)
 neurologic disorder = Significant Distal involvement

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20
Q

Fatigue

A

An inclination to rest even though pain and weakness are not limiting factors
- sense of exhaustion, not muscle weakness, not pain
common complaint of patients with M&S disease
may be prominent even without activity in rheumatic dis.

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21
Q

Fatigue : Differentiation from stiffness + weekness

A
  • Stiffness is a discomfort during movement
  • Weakness is an inability to move normally, especially
    against resistance
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22
Q

Fatigue : Differentiation from Malaise

A

Malaise

  • is an indefinite feeling of lack of health
  • occurs at the onset of an illness
  • often occurs with fatigue but is not a synonymous
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23
Q

Fatigue & malaise can be seen in

A

the absence of identifiable organic

disease, and anxiety, tension, stress, and emotional factors can play a role.

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24
Q

JOINTS- CLINICAL EXAMINATION

A 
Inspection
– Palpation of:
bony landmarks
related joint and soft-tissue structures
– Range of motion assessment
– Special maneuvers to test specific movements
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25
JOINTS - INSPECTION
- joint Symmetry - joint Alignment - bony Deformities
26
JOINTS | INSPECTION AND PALPATION
skin changes of surrounding tissues – nodules – muscle atrophy – Crepitus = audible and/or palpable crunching during movement of tendons or ligaments over bone
27
JOINTS EXAMINATION | RANGE OF MOTION / MANEUVERS
Active mov. (i.e. movements performed by the patient on their own) Passive mov. (i.e. movements performed by the examiner) Resisted mov. (i.e. movements against resistance) ! always compare one side with the other
28
JOINTS EXAMINATION | RANGE OF MOTION
``` General rule: – muscular / tendon problems suggested by reduced active movements, that improve on passive movement – intra-articular disease suggested by reduced range of movements both active and passive ```
29
``` Temporomandibular Joint (TMJ) INSPECTION + PALPATION ```
place the tips of your index fingers just in front of the tragus of each ear and ask the patient to open his or her mouth. The fingertips should drop into the joint spaces as the mouth opens
30
``` Temporomandibular Joint (TMJ) RANGE OF MOTION ```
– Opening / closing – Protrusion / retraction – Lateral / Side to side motion
31
Flexion
Normal range – usually 180 degrees
32
Extension
Normal range ~ | usually 50 degrees
33
Abduction
(Normal range ~ | usually 180 degrees)
34
Adduction
(Normal range ~ | usually 45 degrees)
35
External rotation ( Shoulder )
(Normal range ~ | usually 90 degrees)
36
Internal rotation ( Shoulder )
(Normal range ~ | usually 50 degr)
37
PAINFUL SHOULDERS
1.Pain 2.Pinching 3.Stiffness → Pain characters
38
Pain characters
``` Location: upper arm Radiation into the - forearm - hands - fingers Worsening at night, making sleeping a painful and difficult event Pathology: PAINFUL SHOULDERS ```  when raising the arm
39
ELBOW | INSPECTION + PALPATION
``` epicondyles (medial and lateral) - olecranon process of the ulna Identify: - Tenderness (Press on the epicondyles) - Displacement of the olecranon ``` ``` - grooves between the epicondyles and the olecranon Identify: - tenderness - swelling - thickening ```
40
ELBOW | RANGE OF MOTION
Flexion / extension at the elbow | – Pronation / supination of the forearm
41
The wrist and hand | INSPECTION for
- Swelling over the palmar and dorsal surfaces of the wrist and hand - Deformities of the wrist, hand, or finger bones - Angulation from radial or ulnar deviation - Thickening of the flexor tendons - Flexion contractures in the fingers - Observe the thenar and hypothenar eminences
42
The wrist and hand | PALPATION
``` wrist / distal ulna and radius • anatomic snuffbox • 8 carpal bones • each of the 5 metacarpals • Phalanges (proximal, middle, and distal) Look for:  tenderness  swelling ```
43
WRIST | RANGE OF MOTIONS
1. Flexion 2. Extension 3. Ulnar / radial deviation
44
The wrist and hand Pathologic finding 1. Dupuytren’s contracture
fixed flexion | contracture of the hand where the fingers bend towards the palm and cannot be fully extended (straightened)
45
``` The wrist and hand Pathologic finding ( 2, 3) ```
2. Herbeden’s nodes (distal Phalanges) | 3. Bouchard’s nodes (interPhalangian)
46
The wrist and hand Pathologic finding 4. Rheumatoid Arthritis
- swollen hand (early RA) | - ulnar deviation (late RA)
47
The spine INSPECTION (From the side)
``` spinal curvatures → 1= Cervical lordosis 2=Thoracic kyphosis 3= Lumbar lordosis 4= Sacral kyphosis ```
48
The spine INSPECTION From behind
``` 1="Vertebra prominens" Spinous process of C7 2= 2nd Lumbar vertebra 3= L4-5 inter vertebral space 4= Iliac crests 5= Dimples of Venus (fossae lumbales lateralis) / Sacroiliac joints ```
49
The spine PALPATION tenderness
the spinous process / the paraspinal muscles / the sacroiliac joints
50
The spine | Schober’s test
!!! measures the degree of flexion of the spine Mark the spine at the lumbosacral junction, then 10 cm above and 5 cm below this point. A 4-cm increase between the two upper marks is normally seen. !!! Increases less < 4cm in ankylosing spondylitis
51
Lasegue Maneuver
* The sciatic nerve elongation maneuver performed in clinostatism * It involves raising the pelvic limb in extension to an angle of 90 degrees * If present, pain apear at an angle of less than 30 degrees
52
HIP INSPECTION
``` Assess – level of the iliac crests – leg length discrepancy – muscle wasting – scar ```
53
HIP PALPATION
- tenderness - heat - swelling ] -> around the inguinal areas and the greater trochanter area Measurement of legs length – between the anterior iliac spine to the tip of the medial mallous, with the anterior spines lying at the same transverse level ! compare one side to the other
54
HIP FLEXION + EXTENSION
Normal range ~ 120 degree
55
ADDUCTION
Normal range of movement | ~ 30 degrees)
56
ABDUCTION
Normal range of movement | ~ 45 degrees
57
HIP EXTERNAL ROTATION
Normal range of movement | ~ 60 degrees
58
HIP INTERNAL ROTATION
(Normal range of movement | ~ 45 degrees)
59
The knee and lower leg INSPECTION walking & standing (eg.walk with a limp)
``` Asses for: • muscle wasting • bowing (varus) deformity • knock-kneed (valgus) deformity • sign of inflammation (eg.red or swollen) ```
60
The knee and lower leg | INSPECTION
- genu varum (Varus deformity of the knee) - scar & staples (recent) after a total knee replacement
61
The knee and lower leg | PALPATION
– temperature – Tenderness (Bend the knee to 90 degrees & feel around the medial & lateral joint lines) • the patella • quadriceps tendon • prepatellar & collateral ligaments – popliteal (Bakers) cyst: back of the knee
62
The knee and lower leg Special maneuvers Assessment of fluid in the knee join (3 tests)
–1) The Bulge Sign (for minor effusions) –2) The Balloon Sign (for major effusions) Compress the suprapatellar pouch against the femur. Feel for fluid entering (or ballooning into) the spaces next to the patella under your right thumb and index finger. 3) Ballotting the patella-large effusions Compress the suprapatellar pouch and “ballotte” or push the patella sharply against the femur. Watch for fluid returning to the suprapatellar pouch.
63
Knee + lower leg | Range of motions
– Flexion/extension | – Internal/external rotation
64
Crepitus is usually indicative of
degenerative knee disease (osteoarthritis)
65
The ankle + foot | Range of motions
– Flexion / extension at the ankle (tibiotalar) joint | – In the foot: inversion / eversion
66
The ankle + foot
1. Arthritis , ligaments , injury or infection of the ankle 2. Achilles tendinitis 3. Bursitis 4. Plantar fasciitis 5. Rheumatoid arthritis 6. Gout
67
Arthritis, ligament injury, or infection of the ankle
- localized tenderness | - pain on mobilization
68
Achilles tendinitis
- tenderness - partial tear from trauma - rheumatoid nodules in Achilles tendon
69
Bursitis
- tenderness
70
Plantar fasciitis
pain over the plantar fascia
71
Rheumatoid arthritis
tenderness on compression is an early sign
72
Gout
acute inflammation of the first metatarsophalangeal joint (pain, decreased movements, edema, erythema)
73
DIAGNOSIS
AGE  young: SLE, rheumatic fever, and Reiter's syndrome  middle age: fibromyalgia  old age: osteoarthritis, polymyalgia rheumatica SEX  men: Gout, spondyloarthropathies  women: rheumatoid arthritis, fibromyalgia RACE  whites: giant cell arteritis, and Wegener disease  blacks: sarcoidosis and systemic lupus erythematosus (SLE) FAMILY HISTORY  Familial aggregation:  RA, ankylosing spondylitis, gout,
74
JOINT- EXTRINSEC PAIN
- Cellulitis - typical red streaks and swelling | - Bursitis
75
JOINT PAIN – Intrinsic conditions
Degenerative disorders | Osteoarthritis
76
JOINT DISEASES = ARTHRITIS
1. Osteoarthritis 2. Autoimmune diseases - rheumatoid arthritis - psoriatic arthritis - reactive arthritis 3. Septic arthritis 4. Gouty arthritis/ Pseudogout
77
OSTEOARTHRITIS | DEFINITION
1. Degeneration 2. Progressive loss of cartilage within the joints 3. Underlying Bone damage 4. New Bone formation at the margins of the cartilage
78
OSTEOARTHRITIS
``` Pattern of Spread: – Additive or only 1 joint may be involved Onset: usually Insidious Progression and duration – Slowly progressive, with temporary exacerbations after periods of overuse ``` ``` Associated symptoms: – Swelling: small effusions may be present, especially in the knees – Redness : rarely – Warmth : seldom – Tenderness : Possibly Stiffness: After inactivity Limitations of motions: often develops Generalized symptoms: ABSENT ```
79
RHEUMATHOID ARTHRITIS
1. synovial membranes inflammation 2. cartilage erosion 3. bone erosion 4. ligaments and tendons damage 5. Systemic involvment
80
Joint involvement pattern in | RHEUMATHOID ARTHRITIS
1. Pattern of Spread: – Symmetrically – Additive: progresses to other joints while persisting in the initial ones 2. Onset: – Insidious Usually 3. Progression and duration: – Often chronic, with Remissions and Exacerbations Associated symptoms –Swelling of synovial tissue in joints or tendon sheaths + Subcutaneous nodules – Redness, Warmth and Tenderness: seldom red, often warm, tender –Stiffness: prominent, often for an hour or more in the morning, also after inactivity –Limitation of Motion: often develops –Generalized Symptoms: weakness, fatigue, weight loss,and increased fever
81
Joint involvement pattern in | RHEUMATHOID ARTHRITIS
``` – Hands (PIP / MCP joints) – feet (MTP joints) –Wrists – Knees –Elbows – Ankles ```
82
Early rheumatoid arthritis
MCP joints Swollen Warm Red
83
Late RA
Deformities present. Swan neck deformity of the thumb. Ulnar drift of the MCP joints. Subluxation of the PIP joints.
84
RHEUMATHOID ARTHRITIS | DIAGNOSIS CRITERIA
1. Morning stiffness 2. Arthritis of 3 or more joint areas 3. Arthritis of hand joints 4. Symmetric arthritis 5. Rheumatoid nodules 6. Serum RF 7. Radiographic (erosions or bony decalcification on hand and wrist
85
PSORIATIC ARTHRITIS findings
``` 10-30% of people suffering from psoriasis Inflammatory arthritis Associated signs: Psoriatic Nail lesions splitting of nails → onycholysis Tendinitis =‘sausage-like’ swelling of digits ~ dactylitis ```
86
Reactive Arthritis
autoimmune condition that develops in response to an infection in another part of the body (genitourinary or gastrointestinal infections)
87
Reiter ́s syndrome = 3 symptoms combination:
Arthritis (inflammatory) of large joints RTCD  Eyes inflammation (Conjunctivitis and Uveitis)  Urethritis
88
Septic arthritis
DEFINITION joint infection PATHOGENY:  dissemination of pathogens by blood abscesses or wound infections osteomyelitic focus • dissemination by Contiguity (adjacent soft tissue infection)  direct entry via penetrating trauma iatrogenic means ETIOLOGY Bacteria commonly involved: Staph. aureus, Streptococci, E coli, M. tuberculosis, Salmonella spp.
89
Gout
``` Caused by Deposition of Uric Acid Crystals in the joint that results in subsequent joint inflammation Characterized by – Pain: (burning) severe, sudden, unexpected D – Swelling T – Redness R – Warmth C – Stiffness – Low-grade Fever may also be present occurs commonly in Men in their toes Longstanding Hyperuricemia ``` Other sign - Tophi = uric acid crystal deposits in other tissues – Ear helix – Knees, elbows, hands
90
Arthritis in Rheumatic Fever
``` systemic illness - autoimmune response group A β hemolytic streptococcal pharyngitis - rheumatic heart disease, most serious complication Clinical manifestation Major diagnostic criteria 1. Carditis 2. Polyarthritis 3. Chorea 4. Subcutaneous nodules 5. Erythema marginatum ``` Minor diagnostic criteria 1. Fever 2. Arthralgia 3. Prolonged PR interval on Ecg 4. Elevated acute-phase reactants 2 M / 1 M+ 2
91
Joint involvement pattern in | Rheumatic Fever
Polyarthritis • earliest manifestation of RF (70-75%) • begins in the large joints of the lower extremities (ie, knees, ankles) * Migratory → migrates to other large joints in the lower or upper extremities (ie, elbows, wrists) * NOT Additive * Generally fully recover of joint * IF multiple attacks → destructive arthritis (Jaccoud arthritis)
92
Joint involvement pattern in Rheumatic Fever Arthritis symptoms + signs
``` Symptom • Pain out of proportion to clinical findings reaches maximum severity in 12-24 hours persists for 2-6 days ``` ``` Signs • Swelling • Warmth • Redness • Limited range of motion ```
93
Ankylosing Spondylitis
``` chronic and Progressive form of Seronegative arthritis • autoimmune disease - arthritis of the spine - start 20 - 40 y - Males >>> females Risk factors • Family history of AS • Male gender ```
94
Ankylosing Spondylitis | Symptoms
LOW BACK PAIN • centered over the sacrum • radiate to the groin and buttocks and down the legs • comes and goes • worse at night, in the morning, or when Pt are Not active • Awake from sleep • typically gets better with activity or exercise • SUBSTRATE: bilateral sacroiliitis
95
Ankylosing Spondylitis | less common symptoms
* Eye inflammation or uveitis * Peripheral joint Pain, Heel pain, Hip pain and Stiffness * Fatigue * Slight Fever * Weight loss * Loss of appetite
96
Ankylosing Spondylitis | Joint involved
axial skeleton particularly • sacroiliac and spinal facet joints + Extraspinal involvement
97
Ankylosing Spondylitis | Symptoms and Range of movement suggest diagnosis
1. Low back pain: present for more than 3 months, improved by exercise but not relieved by rest. 2. Limitation of lumbar spine motion (sagittal & frontal) 3. Limitation of chest expansion relative to normal values for age and sex.
98
``` Ankylosing Spondylitis Physical examination (signs) ```
1. Spine & sacroiliac joints • Loss of lateral flexion of the lumbar spine early • tenderness response during percussion over the sacroiliac joints • pain response by springing the pelvis ``` 2. Peripheral joints • restriction of joint motion (Synovitis) Entheses tenderness (entheses are sites of attachment to bone of ligaments, tendons, and joint capsules) ↓ Chest expansion → costovertebral joints involved • Diaphragmatic breathing (ballooning of the abdomen during inspiration) ```
99
Ankylosing Spondylitis | Tests to measure spinal restriction
1.Touching the toes (difficult) 2.Schober test (<4 cm) 3.Chest expansion measurement (↓) in AS the spine → completely rigid → with loss of the normal curvatures and → reduced movement

Symptoms of respiratory system (8 decks)

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