Physical examination of the musculosceletal- and nervous system. Pánczél Pál dr.

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1 Physical examination of the musculosceletal- and nervous system in the practice of internal medicine. Pánczél Pál dr.

2 Bursae = sacks of the synovial membrane fulfilled with synovium. Localised between the skin and the convex surface of the bone, or tendons and muscles and bones and ligaments. tendon muscle enthesis cartilage bone bone joint space in the x-ray picture joint space (virtual) enthesis synovial membrane joint capsule Anatomy of the joints

3 Categories of musculosceletal diseases and the involved anatomical substrates 1. Autoimmune synovitis rheumatoid arthritis 2. Enthesitis, enthesiopathy seronegative spondylarthritides (Bechterew, Reiter) 3. Degeneration of cartilage arthrosis, osteoarthritis, discopathy, spondylosis, spondylarthrosis 4. Cristal induced synovitis gout 5. Bacterial infection induced synovitis purulent arthritis 6. Autoimmune inflammation of the muscles polymyositis/dermatomyositis 7. Localised abnormalities tennis elbow (epicondylitis lateralis humeri) 8. Generalised abnormalities fibrositis syndrome

4 Musculosceletal complaint Articular Nonarticular Noninflammatory Localised Systemic Trauma Osteoarthritis Osteonecrosis Charcot joint Inflammatory Polyarticular Bursitis Tendinitis Osteomyelitis Carpal tunel Fibrositis PMR Polymyositis osteoporosis Monarticular Symmetric Asymmetric Axial acute chronic acute chronic SPA Reiter TBC, Brucella Septic arthritis Gout HBV Serum sickness RA SLE Reactive arthritides Psoriatic arthritis Rheumatic fever

5 Approach to articular and musculosceletal disorders (1) Age: SLE, rheumatic fever, Reiter s sy. - in the young fibrosits - middle ages osteoarthritis, PMR - in the elderly Sex: gout, spondylarthropathies - in males RA, fibrositis - in females Race: PMR -in whites sarcoidosis -in blacks Occupation: heavy physical workers -osteoarthritis, spondylosis secretary -fibrositis, insufficiency of the dorsal paravertebral muscles Familial aggregation: SPA, gout, RA, Heberden type of osteoarthritis Main complaint: when did it start? how did it start? (sudden, gradual, time of day) Precipitating factors? (trauma, excessive or unusual activity, infection /sore throat, urethral discharge, septic laesions/) unusual sexual exposure? (SARA) foreign travel? contact with inefctious disease, drugs, vaccinations? exposure to sunlight or cold?

6 Approach to articular and musculosceletal disorders (2) Number and pattern of involved structures: Gout, septic arthritis - mono/oligoarticular/asymmetric RA - polyarticular/symmetric SPA - axial/oligoarticular/asymmetric RA - upper extremities SPA/Reiter - lower extremities Chronology and evolution of the patient s complaints: Gout - acute onset Osteoarthritis - insidious onset Rheumatic fever - migratory, acute Reiter - additive, acute Associated features: Fever - SLE, septic arthritis, gout Rush - SLE Morning stiffness if the involved joints - RA Eye involvement - Reiter Gastrointestinal involvement - PSS, arthritis associated with IBD, Yersinia induced reactive arthritis Genitourinary tract involvement - Reiter Nervous system involvement - Lyme, vasculitides

7 Examination of the patient (1) General: appearance - well, or ill obvious diagnosis (myxoedema, acromegaly) pallor, pigmentation, skin rashes posture gait Examination of joints: appearenec - overlying skin (colour), swelling, deformity palpation - warmth, nature of swelling (effusion, soft tissue, bony swelling), tenderness active movement - range, pain, crepitus, power passive movement - range, pain, crepitus, stability, are deformities correctible? Examination of soft tissues: muscles - power, wasting tendons - thickenig, localised swelling, tenderness, crepitus, rupture bursae - swelling, tenderness, signs of inflammation ligaments - tenderness, stability (especially in the knee joints) tendon sheats - swelling nodules - tophus, rheumatoid nodules

8 Examination of the patient (2) Complete physical examination. Look particularly for Nonarticular features of RA - nodules, lymphadenopathy, peripheral neuropathy Tophi Rashes (Psoriasis may be minimal or hidden. Look at hands for vasculitic lesions. Look for erythema nodosum, purpura, scleroderma.) Clubbing of fingers or other evidence of malignant diseases (hepatomegaly, lymphadenomegaly) Temporal arteritis Evidence of infection from boils to tbc. Gonorrhoea! Splenomegaly Evidence of gastrointestinal abnormality (CU, Crohn) Fever

9 RA symmetric polyarthritis symmetric polyarthritis small joints of the hands

32 Osteoarthritis asymmetric arthralgia weight bearing joints DIP (Heberden s nodules)

38 Arthritis urica Gout Asymmetric mono- oligoarthritis

52 Paraneoplasia Carcinoma of bronchus (clubbing of the fingers drumstick fingers watch-glass nails)

59 Seronegative spondylarthritides Axial sceleton (enthesitis) + asymmetric oligoarthritis (knee joint, hip joint)

and cervical spine, along with prominence of the abdomen, mild flexion

64 Posture in advanced longterm ankylosing spondylitis. Progressive flattening of lumbar spine and forward stooping of the thoracic and cervical spine, along with prominence of the abdomen, mild flexion contracture of the hip joints, and diminution of vertical height after many years of the disease process.

67 Fixed flexion deformity of the hip joint can be revealed as the contralateral hip joint is maximally flexed to obliterate the exaggerated compensatory lumbar lordosis.

possible, then to bring the arm behind the neck and reach down along the spine as far as possible (to test external rotation).

68 Relatively subtle limitation of motion of the shoulder joint can easily be detected. The patient is asked to bring the arm behind the waist (to test internal rotation) and reach up along the spine as high as possible, then to bring the arm behind the neck and reach down along the spine as far as possible (to test external rotation). In individuals with the normal range of motion of the shoulder joints, these reaches overlap, but in patients with limited range of motion there is a gap between these reaches.

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