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Dd a n i e l l a . s o u s s i 1 @ n h s . n e t MSk and Rheumatology PACES MedED Lecture – 07/11/2023SESSION STRUCTURE • Common presentations and differentials for each joint • Principles of joint examination: Hand, Knee and Shoulder • Special tests for each joint • X-ray interpretation for MSK pathologies • Other rheumatological conditions e.g. SLE, PMR, AS SBA 1 Johnny, a 6 year old child with sickle cell disease presents to paeds A&E complaining of knee pain. When you see him, you see that he tries to avoid putting weight on his knee, and has a temperature of 38.6 degrees. What is the next best step in management? A) Obtain blood sample including WCC, CRP B) Conduct joint aspiration and send sample off for MC&S and crystals C) Prescribe antibiotics D) Sent Johnny home with simple analgesia E) Obtain a joint x-ray SBA 1 paeds A&E complaining of knee pain. When you see him, younts to Common organisms: see that he tries to avoid putting weight on his knee, and has 1. Staph aureus a temperature of 38.6 degrees. 2. Strep pneumoniae 3. Salmonella species in sickle cell What is the next best step in management? patients A) Obtain blood sample including WCC, CRP (of secondary use) Cardinal signs of B) Conduct joint aspiration and send sample off for septic arthritis: MC&S and crystals (septic arthritis until proven • Hot otherwise) • Swollen • Painful knee C) Prescribe antibiotics (will do eventually) • Inability to weight D) Sent Johnny home with simple analgesia bear E) Obtain a joint x-ray (MRI would be better but even still • Temperature pathology will not show on imaging unless there is bone • Limited ROM involvement) Knee – Common presentations • Joint pain (acute and chronic) • Reduced range of motion Knee – Common presentations Joint pain (acute and chronic): • Osteoarthritis • Crystal arthropathy (esp. Pseudogout) • Ligamentous injury • Meniscal injury • Fracture • Septic arthritis Knee – Common presentations Reduced range of motion: • SEPTIC ARTHRITIS (painful swollen knee, cannot weight bear) • Fracture • Osteoarthritis Examination introduction Introduction (WIIPPPE) • Wash your hands • Introduce yourself (name and position) • Identity of patient (confirm name and date of birth) • Permission (consent and explain examination: “I’m going to examine your X now, is that OK?”) • Pain? • Position • Expose Knee examination Look, feel, move + special tests + gait Look: Feel: Move (active and Special tests: passive): • Anterior drawer (ACL) • Erythema • Sweep test • Joint swelling • Patellar tap • Flexion 0-140° • Lachman's test (ACL) • Scars • Joint crepitus • Extension -10-0° • Posterior drawer (PCL) • Deformity • Patellar tenderness or • Valgus stress (MCL) laxity • Muscle wasting (LMN, • Varus stress (LCL) disuse atrophy etc.) • Joint line tenderness – • Posteriorly – baker's cyst fracture, meniscal or • Patellar tracking collateral ligament injury • McMurray's (offer – • Fixed flexion deformity • Baker's cyst • Posterior sag sign assesses medial and lateral • Popliteal aneurysm menisci)Knee examination Knee exam presentation and further Ixs: *Today I examined X, a X-year-old M/F. On general inspection, the patient appeared comfortable at rest, with no signs of MSk disease. There were no medical paraphernalia around the bed. The patient had a normal gait and knee joint appearance. There was no joint crepitus and the range of movement of both knee joints passively and actively was within normal range. There were no abnormalities noted on the assessment of the ligaments of either knee joint. Special tests were negative. In summary, these findings are consistent with a normal knee joint examination. For completeness, I would like to perform the following further assessments and investigations:* 1. Neurovascular examination of both lower limbs. 2. Examination of the joints above and below (e.g. ankle and hip). 3. Further imaging if indicated (e.g. X-ray and MRI). https://geekymedics.com/knee-examination/Knee X-rays: Osteoarthritis LOSS: • Loss of joint space • Osteophytes • Subchondral cysts • Subchondral sclerosisKnee X-rays: Replacements https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186 /s12891-019-2508-1 https://www.hss.edu/conditions_partial-knee-replacement.asp SBA 2 wrist. Her X-ray indicates a fracture in the distal radius, that is dorsally displaced and angulated. What is the diagnosis? A) Smith's fracture B) Barton's fracture C) Colle's fracture D) Chauffeur's fracture E) Scaphoid fracture SBA 2 Mrs Smith, an 80 year old lady presents to A&E complaining of pain in her wrist. Her X-ray indicates a fracture in the distal radius, that is angulated.isplaced (backwards) and What is the diagnosis? A) Smith's fracture (distal radius with volar (forward) displacement of fragments) B) Barton's fracture (fracture dislocation of the radiocarpal joint) C) Colle's fracture D) Chauffeur's fracture E) Scaphoid fracture (fracture of the radial styloid). Presenting an Xray This is a PA(or AP) and lateral view X-ray of patient X taken on day and time. It is adequate (shows joint proximal and distal) or inadequate. The most obvious abnormality is... Other features are... OLD ACID Open vs closed Location Degree (complete vs incomplete) Articular involvement Comminution and pattern Intrinsic bone quality Displacement, angulation, rotationFracturesShoulder joint Shoulder examination Look, feel, move + special tests Look: Feel: Move (active, passive, Special tests: • Erythema • Temperature (septic or simple and compound): • Winging of the scapula • Joint swelling (effusion, inflammatory arthritis) • Flexion (raise arms (ipsilateral serratus anterior inflammatory arthropathy) muscle weakness --> long • SC joint forwards until pointing to thoracic nerve injury) • Scars (past surgery hints) • Clavicle • Empty can test (supraspinatus – • Bruising (recent trauma or ceiling) 150-180° tear or impingement causing surgery) • AC joint • Extension 0-40° pain) • fractures, dislocation) • Acromion • Abduction 0-180° • Painful arc (impingement • Coracoid process of syndrome – pain between 60- • Deformity • Adduction 30-40° 120°) • Muscle wasting: scapula • Resisted external rotation • Disuse atrophy, LMN • Head of humerus • Internal rotation 80-90° (weakness in infraspinatus and • Axillary nerve injury --> deltoid wasting • GT of humerus (subscapularis) teres minor) • trapezius wastingnerve lesion --> • External rotation 80-90° • Resisted internal rotation • Chronic rotator cuff • Bicipital groove (weakness in subscapularis) supraspinatus/infraspinatus w•stScapular spine (infraspinatus, teres minor) • Scarf test (AC joint pathology e.g. OA) https://geekymedics.com/shoulder-examination/ Shoulder pathology and examination findings Adhesive capsulitis • Stiffness and pain • Significant reduction in the range of both active and passive movement on examination • Palpation does not typically cause pain • Risk factors include surgery, prolonged immobility and trauma. Further examinations and investigations: • Neurological examination of Axillary nerve palsy upper limbs • Typically caused by shoulder dislocation. • Loss of sensation over the lateral deltoid region (regimental patch) • Examination of the joints above • Deltoid muscle weakness (loss of shoulder abduction). and below (cervical spine and elbow) • Further imaging if indicated (e.g. Shoulder impingement syndrome (SIS) X-ray, MRI). • Inflammation of rotator cuff muscle tendons as they pass through the subacromial space. • Most often associated with supraspinatus tendonitis. • Symptoms include pain, weakness and a reduced range of active movement. • Normal passive range of motion is preserved. • Symptoms exacerbated by overhead movement of the limb, typically during abduction between 60-120°, which is referred to as a ‘painful arc’ of movement. https://geekymedics.com/shoulder-examination/X-ray findings SBA 3 Samantha, a 72 year old retired seamstress presents to you in the GP clinic complaining of pain in her hands. Her hands look as follows: What is the diagnosis? A) Rheumatoid arthritis B) Osteoarthritis C) OA and RA D) Gout E) Fracture SBA 3 Samantha, a 72 year old retired seamstress presents to you in the GP clinic complaining of pain in her hands. Her hands look as follows: What is the diagnosis? A) Rheumatoid arthritis B) Osteoarthritis C) OA and RA D) Gout E) FractureHands - OsteoarthritisHands – RA vs OA hands Hand examination • Look, feel, move + special tests • Look: • Hands: Bouchard's, heberden's, boutonniere, swan-necking, gottron's papules, muscle wasting etc. • Nails: psoriasis: onycholysis, nail pitting etc. • Other: under elbows for psoriatic plaques and rheumatoid Psoriatic nail changes and dactylitis nodules, behind ears for gouty tophi. • Feel: Temperature, deformity, nodules, test gross sensation • Move (active and passive): pain and stiffness? • Wrist flexion and extension, finger flexion and extension, thumb flexion and extension, finger abduction and adduction • Pincer grip (coin), power grip (squeeze) • Tests: Phalens test (median nerve), Finkelstein test (De Gottron's papules - Dermatomyositis Quervain's tenosynovitis) https://oxfordmedicaleducation.com/clinical- examinations/rheumatology-examination/hand-examination/ Hands - Further Exams and Ixs • Thank patient, ensure they’re comfortable and ask if they need any help in getting dressed and wash your hands. • Further examinations: • Other joints • Respiratory (if concern about rheumatoid arthritis, which is associated with pulmonary fibrosis and pleural effusions) • Abdomen (if concerned about rheumatoid arthritis [splenomegaly in Felty’s sundrome]) • Further investigations: • Bloods • FBC (anaemia of chronic disease) • U&Es (renal impairment with vasculitis and for drug dosing) • LFT (baseline, pre-medication) • ESR and CRP (correlates with disease activity in rheumatological conditions) • TFT (if autoimmune concern) • Urate (if considering gout) https://oxfordmedicaleducation.com/clinical- examinations/rheumatology-examination/hand-examination/ Hands - Further Exams and Ixs • Immunology • Rheumatoid factor • Does not rule RA in or out • Positive in up to 20% of normal population • Also positive in other AI disease e.g. Sjogrens, SLE, autoimmune liver disease • Negative in around 30% of patients with RA, may become positive later on in disease course • Anti- CCP antibody • Does not rule RA in or out but more specific than RF and predictor of poor prognosis • HLA-B27 • Hand XR and USS • To look for characteristic erosions • Joint aspiration • If effusion and concern about diagnosis or septic process https://oxfordmedicaleducation.com/clinical- examinations/rheumatology-examination/hand-examination/ Hands – Carpal tunnel syndrome Management: • Conservative: Wrist splinting, more frequent breaks, avoidance of tasks which worsen symptoms. • Medical: NSAIDs, corticosteroids • Surgical: Carpal tunnel release Wasting of the thenar eminence in prolonged median nerve compression Back pain differentials Rheumatological: • Ankylosing spondylitis • Psoriatic arthritis Neurological: • Spinal stenosis • Nerve root compression • Radiculopathy • Cauda equina Malignancy: • Sarcoma • Multiple myeloma • Metastasis Musculoskeletal: • Fracture • Muscular pain • Sacroiliac joint dysfunction Biologics: TNFα inhibitors used: adalimumab, etanercept IL-17 inhibitors used: Seronegative spondyloarthropathy secukinumab, ixekizumab Extra-articular manifestations: • Enthesitis e.g. plantar fasciitis • Uveitis • Psoriasis • Inflammatory bowel disease • Pulmonary fibrosis • Aortitis, aortic insufficiency, heart block • Amyloidosis (rare) https://www.osmosis.org/learn/Seronegative_arthr itis:_Clinical_practiceSystemic lupus erythematosus 4/11 American College of Rheumatology criteria --> SLE high sensitivity and specificity for diagnosis: SOAP BRAIN MD Multisystem autoimmune inflammatory disorder • Serositis (pleurisy, pleuritis, pleural effusion, Aetiology is unknown pericarditis) Tissue damage may be caused by vascular immune • Oral or nasal ulcers complex deposition • Arthritis (in 2 or more peripheral joints) • Photosensitivity Risk factors: • Bloods (pancytopaenia, haemolytic anaemia, • Young female leukopaenia, thrombocytopaenia) • Afro-Caribbean or Chinese descent • Renal disease (urine casts, proteinuria, nephrotic • Viruses e.g. EBV syndrome) • Drugs e.g. isoniazid, procainamide • ANA (not specific as raised in many conditions) • Immunological disorder (anti-dsDNA (60%), anti- Management: smith antibody, anti-phospholipid) • Conservative: lifestyle, diet, exercise, flu jab, family • Neurological disease (depression, psychosis, planning, physiotherapy seizures) • Medical: analgesia • Malar rash (butterly rash) • Specialist: steroids, hydroxychloroquine, • Discoid rash cyclophosphamide, MMF, azathioprine, biologics SBA 4 Vanessa, a 59 year old woman presents with history of headache, and jaw pain. She has a long standing history of shoulder and neck pain. What is the next best step? A) Temporal artery biopsy B) USS temporal artery C) Assess for visual impairment D) Check the ESR E) Prescribe steroids SBA 4 Vanessa, a 59 year old woman presents She has a long standing history ofpain. shoulder and neck pain. What is the next best step? A) Temporal artery biopsy B) USS temporal artery steroids and admission if present)V D) Check the ESR E) Prescribe steroids Polymyalgia Rheumatica Inflammatory condition of unknown cause, characterised by severe bilateral pain and morning stiffness in the shoulder, neck and pelvic girdle with no weakness. 15% of PMR patients will develop giant cell arteritis 40-50% of patient with GCA will have PMR More common in >50yrs ESR/CRP raised – monitor this for treatment Screen for risks of diabetes as will be starting them on steroids Management: Conservative: diet and exercise Medical: 15mg prednisolone, bisphosphonates, vitamin D, PPI may be started THANK YOU FOR COMING! PLEASE FILL IN THE FEEDBACK FORM! d a n i e l l a . s o u s s i 1 @ n h s . n e t