Rheumatology Final Med revision programme Dr. David Kane Consultant Rheumatologist AMNCH & TCD

Transcription

1 Rheumatology Final Med revision programme 2007 Dr. David Kane Consultant Rheumatologist AMNCH & TCD

2 GALS Screening examination

3 Screening examination for musculoskeletal disorders (GALS) Should take 2 minutes Gait, Arms, Legs, Spine (GALS) Done as part of Major case Regional Examination of Musculoskeletal System is for more thorough examination

4 GAIT Patient Standing Walk a few steps, turn, walk back Observe: Symmetry, smoothness and turn Inspect while standing Front } Muscle bulk, symmetry Back } Head to Toe Limb alignment, shape Side } Spine and pelvis

5 Spine Do during initial standing inspection Inspect for scoliosis, lordosis, kyphosis Ask patient to tilt head to each side Assess lateral flexion of the neck Ask patient to bend to touch their toes Place two fingers over lumbar spine to assess lumbar flexion

6 Arms Patient Standing: Ask patient to put hands behind head Tests shoulder abduction, external rotation, elbow flexion Extend arms, palms down, fingers outstretched Joint swelling or deformity Turn hands over Muscle bulk, deformity Make a fist Squeeze fingers Grip strength Bring each finger in turn to meet the thumb Assess fine precision pinch Squeeze MCP joints Watch patient s face!

7 Legs Patient lying on couch Flex and extend both knees Feel for crepitus Assess internal rotation of the hip Perform a patellar tap on each knee? Effusion Inspect soles of feet? Swelling, deformities, calluses Squeeze MTP joints Watch patient s face!

8 GALS Gait Appearance Movement Arms Legs Spine

9 GALS Appearance Movement Gait Arms Legs Spine Swollen wrists Swollen knees Reduced movement wrists Reduced movement knees Symmetrical inflammatory polyarthritis

10 Regional examination of the Upper Limb and neck

11 General Principles of Joint Examination Inspection..Look Palpation Feel Active motion Move patient puts joint through full range of movement Passive motion when active range of motion is reduced Resisted movements (provocative tests) Special tests Special Tests

12 Theory Active joint movement Painless / full Painful / restricted Joint / muscle/ tendon all normal Passive movement Painless and full Painful muscle/ tendon problem Joint problem Resisted movements Test individual muscles

13 The Upper Limb Hand Wrist Elbow Shoulder

14 Examination of Hand & Wrist Inspection Palpation Active motion Passive motion Resisted movements Special tests

15 Examination of Hand & Wrist Patient Sitting, Hands resting on a pillow LOOK.Patients hands palm down Swelling, deformity, muscle wasting, scars Skin changes: thinning, bruising, rashes Nails: psoriasis, nailfold vasculitis Symmetrical or assymetrical Pattern: DIP, PIP, MCP, wrists.patient turns hands over?difficulty radioulnar jt problem Muscle wasting (thenar or hypothenar), palmar skin, scars

16 Common Nail signs Psoriasis (onycholysis, pits) Vasculitis/ nailfold infarcts/ Splinters Koilonychia ("spoon shaped, iron deficiency) Leukonychia (low albumin) Beau's Lines growth interruption due to severe illness/ chemotherapy Clubbing

17 Psoriatic Nail dystrophy Pitting Hyperkeratosis Onycholysis Brittle

18 Nailfold infarcts

19 Common Hand signs Psoriasis Joint erythema/ swelling (spindled fingers) Whole finger swelling (dactylitis) Deformity: Swan-neck (DIP flexed PIP hyperextended) Boutonnière (DIP hyperextended PIP flexed) Z-thumb (hyperextended IPJ) Ulnar deviation MCPs

20 Plaque psoriasis Common sites: extensor elbows, knees, scalp Well demarcated, salmon pink, silver scales Extent does not correlate with perceived morbidity

21 Early synovitis of MCPs and PIPs

22 Rheumatoid Arthritis

23 Swan-neck / Boutonnière

24 Psoriatic Dactylitis

25 Osteoarthritis of small joints of the hand PIP - Bouchard s s node DIP - Heberden s node

26 Common Hand signs : Lumps Heberden nodes (DIPJ, bony OA) Bouchard nodes (PIPJ, bony OA) Rheumatoid nodules Gouty Tophi Ganglia (firm, transilluminate, synovial esp wrists) Cutaneous calcinosis (scleroderma)

27 Rheumatoid nodule:

28 Gouty Tophi

29 Common Wrist signs "Piano-Key" ulna RA destroying distal radioulnar ligaments Square hand deformity OA 1 st carpometacarpal joint Previous surgery (carpal tunnel) Ganglion

30 Examination of Hand & Wrist FEEL.Patients hands palms up Check Pulses (?Raynauds) Feel thenar / hypothenar muscle bulk, tendons Assess light touch sensation over thenar / hypothenar eminences.patient turns hands palms down Assess radial nerve sensation Check temperature over MCPs / wrists MCP squeeze test Bimanual palpation of any swollen tender small jts Palpate wrists and ulnar border to elbow

31 Examination of Hand & Wrist MOVE Patients hands palms down Straighten fingers Make fists passive movement if active impaired Active (Prayer sign) and passive movements of wrists Check Phalen s if indicated.neurological Assess median (thumb abduction) and ulnar (spread fingers) power

32 Examination of Hand & Wrist FUNCTION Patients hands palms down Grip two fingers Pinch (Thumb, index, middle) Pick up small object coin Do up button Hold pen, write name

33 The Elbow Inspection..LOOK Palpation FEEL Active motion MOVE Passive motion Resisted movements

34 Examination of Elbow LOOK Look from in front for carrying angle and from side for flexion deformity Skin changes: scars, rashes, psoriasis, muscle wasting, rheumatoid nodules, olecranon bursitis FEEL Temperature at front and back of joint Palpate head of radius, joint line, epicondyles, olecranon Synovitis best appreciated between olecranon and lateral epicondyle

35 Examination of Elbow MOVE Hinge joint flexing 0-150º Pronation/ supination with inferior radio-ulnar joint (90º each way from mid-prone) Functional position is with elbow flexed at 90º FUNCTION Reach hand to mouth / back of head

36 Resisted movements at the elbow Resisted wrist extension pain over lateral epicondyle Resisted wrist flexion pain over medial epicondyle Epicondylitis

37 The Shoulder Inspection Palpation Active motion Passive motion Resisted movements Special tests

38 Examination of Shoulder LOOK Shoulder fully exposed: inspect front, side and back Scars, rashes, muscle wasting, swelling, posture FEEL Temperature over front of joint Palpate sternoclavicular joint, clavicle, acromioclavicular joint, scapula Palpate the joint line front and back Palpate the muscle bulk of supraspinatous, infraspinatous and deltoid

39 Examination of Shoulder MOVE Abduction 0-180º, painful arc at º suggests rotator cuff problem External rotation lost in capsulitis Internal rotation Flexion Extension FUNCTION Reach hand to back of head and behind back

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41 Resisted movements at the Shoulder: the rotator cuff Supraspinatus Pain on resisted abduction at 90º (best assessed with the shoulder internally rotated) Subscapularis Pain on resisted internal rotation Infraspinatus (and teres minor) Pain on resisted external rotation

42 The Shoulder Inspection Palpation Active motion Passive motion Resisted movements Special tests

43 Special shoulder tests Acromioclavicular provocation Kiss the inside of your elbow Speed s test (biceps) Resisted shoulder flexion with extended elbow Yergason s test (biceps) Resisted supination with elbow flexed 90º Hawkins sign Abduct externally rotated arm 90º, then internally rotate - causes shoulder pain with supraspinatus impingement

44 Cervical Spine Active movements Flexion Extension (lost first in spondyloarthropathies) Lateral flexion Rotation Palpation for tenderness Neurological examination