6. Passive movement
• Joint must be put through a full range of movement. Joint
movement may be active performed by the patient or
passive performed by the examiner.
• Limitation of passive movement indicates something
wrong in or around the joint and it is more specific to joint
problem as compared to the active movement .
• Movement must be attempted gently and it wil be
restricted if the joint is painful, having tense effusion or
fixed deformity. The joint may have limited extension
(called fixed flexion deformity) or limited flexion (called
fixed extension deformity).
• Instability of joint that is characterized by abnormal
movement is usually due to weak surrounding ligaments.
It is tested by attempting to move the joint gently in
abnormal direction.
7. Rheumatoid Arthritis
• is a chronic symmetrical polyarthritis of
unknown cause.
• RA is characterized by chronic
inflammatory synovitis of mainly peripheral
joints along with systemic disturbances
and extra-articular features.
• Course of disease is prolonged with
exacerbations and remissions
9. Etiology
• Genetic factor
• Autoimmunity
• Immune complexes are common in the
synovial fluid and circulation
• There is defect in cell mediated immunity
• Female gender
• Cigarette smoking
10. Signs
• Swelling
• Warmth
• Tenderness
• Limitation of movement
• Deformities
• Subcutaneous nodules
• Extra articular features
12. Pattern of joint involvement
• Proximal interphalangeal &
metacarpophalangeal joints of fingers
• Wrist, knee, ankle and toe
• Distal interphalangeal joint spared
13. Spinal cord and vertebral body
• The spinal cord is shorter than the vertebral
column, each spinal cord segment at lower
levels is located above the similarly numbered
vertebral body.
Spinal cord segment Relationship Vertebral body
C1~C4 = C1 ~ C4
C5~T4 - 1 C4 ~ T3
T5~T8 - 2 T3 ~ T6
T9~T12 - 3 T6 ~ T9
L1~L5 = T10 ~ T12
S1~Co1 = L1
15. Question
• Which spinal segment is involved in the
injury of the C4 vertebral body?
----- spinal segment
16. Question
• Which spinal segment is involved in the
injury of the T3 vertebral body?
----- spinal segment
17. Question
• Which spinal segment is involved in the
injury of the T7 vertebral body?
-----spinal segment
18. Deformities
• Synovial effusion of
knee
• Valgus and varus
deformities of knee
joint
• Spindling of fingers
• Swan neck deformity
of hand
• Buttonhole deformity
of hand
• Z-deformity of thumb
• Carpal tunnel
• Lateral deviation of
the toes of the feet
• Subluxation of
metacarpophalangeal
joints of hand
• Subluxation of
metatarsophalangeal
joints of feet
• Atlanto-axial
subluxation
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30. investigation
• There is no specific test for the diagnosis
of RA, but there are investigations which
may be helpful in the diagnosis of RA.
1) Rheumatoid factor –RA factor
2) ANA –antinuclear antibodies
3) CBC, CP, ESR
4) RADIOGRAPHY
5) SYNOVIAL FLUID ASPIRATION
31. You can see positive RA factor in
diseases like
• Normal population: elderly person,
relatives of patients with rheumatoid
arthritis
• JD: Sjorgens syndrome 95%, rheumatoid
arthritis 70%, SLE 50%, systemic sclerosis
30%, polymyositis/ dermatomyositis 50%,
mixed connective tissue disease
• Autoimmune chronic active hepatitis
• Chronic infection : TB, infective
endocarditis, leprosy, kalaazar
32. X-ray features in progression of RA
Stage 1- peri-articular
osteoporosis
Stage 2- loss of articular
cartilage
Stage 3- bony erosions
Stage 4- subluxation and
33. Diagnosis criteria of RA
American Rheumatism Association revised
criteria
• Morning stiffness of more than 1hr
• Arthritis of 3 or more joint areas
• Arthritis of hand joints
• Symmetrical arthritis
• Rheumatoid nodules
• Rheumatoid factor
• Radiological changes
Duration of 6 weeks or more
Diagnosis of RA made with 4 or more criteria
35. Rheumatic fever
Migratory arthritis
Raised ASO –AntiStreptolysin O titer
Dramatic response to aspirin
Carditis and erythema marginatum may
occur in adults but chorea and
subcutaneuous nodules virtually never do
39. Osteoarthritis
• No systemic features
• Joint pain is characteristically relieved by rest
while the pain of RA is increased by inactivity.
• Morning stiffness is much less and for short period
• In contrast to RA, it spares wrist and
metocarpophalangeal joints and commonly
involves distal interphalangeal joints to produce
heberden nodes especially in women.
• Joint swelling is hard due to bony hypertrophy.
Slight effusion may be present particularly in the
knee, while in RA joint swelling is soft due to
effusion and synovial thickening.
• It mostly involves weight bearing joints e.g. spine,
hip, and knee.
40. Gouty arthritis
• Intermittent and monoarticular in early
years, later it may become polyarticular
that mimics RA. Gouty tophi can resemble
rheumatoid nodules.
• Early history of intermittent monoarthritis
and the presence of synovial urate crystals
are distinctive features of gout.
41. Septic arthritis
• Sudden onset of acute arthritis usually
monoarticular and most often are weight
bearing joints and wrists.
• Fever & chills.
• Frequent presence of primary focus of
infection elsewhere e.g. gonococcal infection,
infective endocarditis. I/V drug abuse.
• Joint effusion are large, with WBC count
more than 50000/microL.
• Gram stain and culture are mostly positive.
• Response to appropriate antibiotics.
42. Other D/D are polymyalgia rheumatica,
seronegative arthritis, postviral arthritis
e.g. hepatitis B & hypertropic pulmonary
osteoarthropathy.
46. Single Choice Questions
• Q1.
• A 12yo boy is admitted to the ED following a fall. On
examination, there is deformity and swelling of the
forearm. The ability to flex the fingers of the affected
limb is impaired. However, there is no sensory
impairment, imaging confirms a displaced forearm
fracture. Which of the nerves listed below is likely to
have been affected?
A. Ulnar
B. PIN –posterior interosseous nerve
C. AIN- anterior interosseous nerve
D. Axillary
E. Radial
47. Single Choice Questions
• Q2.
• Which of the muscles listed below is not
innervated by the median nerve?
A. Flexor pollicis brevis
B. Lateral two lumbricals
C. Pronater teres
D. Opponens pollicis
E. Adductor pollicis
48. Single Choice Questions
• Q3.
• A 25 yo man is involved in a fight outside a
nightclub and sustains a laceration to his right
arm. On examination, he has lost extension of the
fingers in the right hand. Which of the nerves listed
below is most likely to have been divided?
A. Median
B. Musculocutaneous
C. Radial
D. Ulnar
E. Axillary
49. Single Choice Questions
• Q4.
• Which of the structures listed below
articulates with the head of the radius
superiorly?
A. Capitulum
B. Trochlea
C. Lateral epicondyle
D. Ulna
E. Medial epicondyle
50. Single Choice Questions
• Q5.
• A 27 yo man falls and sustains a fracture
through his scaphoid bone. From which of the
following areas does the scaphoid derive the
majority of its blood supply?
A. From its proximal medial border
B. From its proximal lateral border
C. From its proximal posterior surface
D. From the proximal end
E. From the distal end -c
51. Single Choice Questions
• Q6.
• Which of the nerves listed below is directly
responsible for the innervation of the lateral
aspect of flexor digitorum profundus?
A. Ulnar
B. AIN- anterior interosseous nerve-c
C. Radial nerve
D. Median nerve
E. PIN- posterior interosseos nerve
52. Single Choice Questions
• Q7.
• The first root of the brachial plexus
commonly arises at which of the following
levels?
A. C3
B. C5-c
C. C6
D. C7
E. C8
53. Single Choice Questions
• Q8.
• When the brachial plexus is injured in the axilla as
a result of a crutch palsy or Saturday palsy or
sleep while your partner is tugged in your armpit
like cuddling position, which of the nerves listed is
most commonly affected?
A. Thoracodorsal nerve
B. Suprascapular nerve
C. Radial nerve -c
D. Ulnar nerve
E. Long thoracic of bell nerve
54. Single Choice Questions
• Q9.
• A 21 yo Elman football club player injuries his right
humerus and on examination is noted to have
minor sensory deficit overlying the point of deltoid
insertion into the humerus. Which of the nerves
listed below is most likely to have been affected?
A. Radial
B. Axillary -c
C. Musculocutaneous
D. Median
E. Subscapular
55. Single Choice Questions
• Q10.
• Which of the following muscles does not
attach to the radius?
A. Pronator quadratus
B. Biceps
C. Brachioradialis
D. Supinator
E. Brachialis -c
56. Single Choice Questions
• Q11.
• How many phalanges are there in the
hand?
A. 10
B. 12
C. 13
D. 14-c
E. 15
57. Single Choice Questions
• Q12.
• A 22 yo attends clinic complaining of tingling
in his hand. He has radial deviation of his
wrist and there is mild clawing of his fingers.
With the 4th and 5th digits being relatively
spared. What is the most likely lesion?
A. Ulnar nerve damage at the wrist
B. Ulnar nerve damage at the elbow -c
C. Radial nerve damage at the elbow
D. Median nerve damage at the wrist
E. Median nerve damage at the elbow
58. Single Choice Questions
• Q13.
• Which of the following is not an intrinsic
muscle of the hand?
A. Opponens pollicis
B. Palmaris longus-c
C. Flexor pollicis brevis
D. Flexor digiti minimi brevis
E. Opponens digiti minimi
59. Combination Therapy
• Combination therapy can be considered
for patients who failed to respond
individual agent
• The combination of methotrexate
chloroquine and sulphasalazine is more
effective than methotrexate alone
• The combination of cyclosporin and
methotrexate is more effective than
methotrexate alone
60. Newer Therapy
• Tumor necrotic factor (TNF) inhibitor:
It combines with circulating TNF which is one of
the major cytokines responsible for
inflammation in rheumatoid arthritis
etanercept, injected as 25 mg twice weekly
show good short-term efficacy and safety for
reduction of inflammation. Side effect is local
irritation at the site of injection. It is an
expensive drug.
• Interleukins (IL-1 & IL-6) receptor blocker
61. Follow-up
• Ask the patient for severity of joint pain,
duration of morning stiffness, fever, fatigue
and weight loss.
• Look for joint swelling, deformities
distribution of involved joints and wasting
of muscle around the joint. Feel for the
warmth & tenderness. Move to assess
range of passive movement & muscle
power.
• Examine for extra-articular manifestation
• Make sure that the patient is taking
62. Prognosis
The course and prognosis in RA are very
variable. After 10 years the disease
pattern is as following
• Complete remission in 25%
• Moderate impairment in 40%
• Severe disability in 25%
• Severely crippled 10%
63. Poor prognostic factors
• High titers of rheumatoid factor
• Insidious onset of disease
• More than a year of active disease without
remission
• Early development of nodules or erosion
• Extra – articular manifestations
• Severe functional impairment
64. Surgical procedures in RA and
OA
• Soft tissue release (decompression)
• Tendon repairs and transfers
• Synovectomy
• Osteotomy
• Excision arthroplasty
• Joint replacement
• Arthrodesis
65. Felty’s Syndrome
• Felty’s syndrome is the association of
splenomegaly and neutropenia with
rheumatoid arthritis involving less than 1 % of
RA patients
Age of onset 50-70
F greater than M
Incidence less than 1% RA patients
Long –standing RA
Deforming but inactive disease
seropositive
66. Common clinical features
• Splenomegaly
• Lymphagenopathy
• Weight loss
• Skin pigmentation
• Keratoconjunctivitis sicca
• Nodules
• Vasculitis
• Leg ulcers
• Recurrent infections
68. Laboratory findings
• Anemia
• Neutropenia
• Thrombocytopenia
• Impaired T and B cell immunity
• Abnormal liver function
69. Osteoarthritis
• Osteoarthritis or degenerative bone
disease is the end-result of variety of
patterns of joint failure, and is
characterized by degeneration of articular
cartilage and simultaneous proliferation of
new bone, cartilage and connective tissue.
Its greatest impact is on weight-bearing
joints e.g hips and knees. There are no
extra-articular features and no systemic
illness
70. Etiology
• Primary
Etiology is un-known
• Secondary
When degenerative joint changes occur in
response to a recognizable local or
systemic factor
72. Pathogenesis
• Osteoarthritis is a disease of cartilage.
Different stimuli can start the degenerative
process but the two most obvious are :
Mechanical insults e.g trauma
Biochemical abnormalities of cartilage (the
chondrocytes in cartilage are believed to
initiate the deterioration by releasing
enzymes that degrade collagen and
protogylcan. Break in the collagen fibers
allow the uptake of water, as a result cartilage
swells and splits)
73. Pathology
• Progressive cartilage loss until hard bone
is all that remains
• Synovial membrane heavily infiltrated with
mononuclear cells
• Thickening of subchondral bone with cyst
formation
74. Pattern of joint involvement
Nodal osteoarthritis
Non-nodal osteoarthritis
Erosive osteoarthritis
Osteoarthritis of knees
77. Clinical features
• The joints most frequently involved are
those of spine, hips, knees and hands.
The disease is confined in one or only a
few joints in the majority of patients
78. Symptoms
• Pain
-Typically in the knees, hip, hands.
-worst in the evening
-aggravated by use and relieved by rest
-intermittent at first but later chronic
• Morning stiffness
-usually lasting up to half an hour, stiffness also after
sitting
• Disability
-movement in the affected joints becomes increasingly
limited, initially as a result of pain and muscular
spasm, but later because of capsular fibrosis,
osteophyte formation and remodeling of bone.
79. Signs
• Joint swelling
-characteristically hard and bony sometimes with associated
effusion
• Crepitus
-on movement may be felt or even heard
• Muscle wasting
-wasting of the muscles around the affected joints
• Joint deformities
-particularly in knee joint,valgus (outward) or varus (inwards) or
flexion deformities are seen with instability of the joint due to
absence of normal muscular control as a result of muscle
wasting
80. Hands
• Heberden’s nodes
-these are bony swelling at the distal
interphalangeal joints of the fingers and
bouchard’s nodes at the proximal
interphalangeal joints.
-at first the joints are often red, warm,
swollen and very tender (hot-heberden
nodes), later the inflammation disappear
leaving knobby but often painless swelling
82. Differential diagnosis
• Osteoarthritis
- Distal interphalangeal joint involvement
- Number of joints involved is less
• Rheumatoid arthritis
- proximal interphalangeal
metacarpophalangeal joints involvement
- Number of joints involved is more
83. Investigation
X-ray
Narrowing of the joint space: due to loss of
the cartilage
Formation of osteophytes at the margin of the
joints
Sclerosis of the underlying bone
Cyst formation
Blood
• Blood count & ESR are characteristically
normal
Synovial fluid
-synovial fluid is viscous and has a low cell
84.
85. Management
• General measures
-weight loss in obese patient
-rest and avoidance of undue trauma and
physical stress
-suitable walking stick
-change in occupation to lighter work
86. • Drug treatment
-there is no drug to reverse the pathological
changes. For the symptomatic relief non-
steriodal anti-inflammatory drugs
(NSAIDs) can be used. Intra-articular
corticosteriods can be used for
inflammatory exacerbations. Injections
should be preceded by aspiration of any
fluid in the joint
87. • Physical therapy
-application of heat may give some relief
-proper exercises are useful to maintain
muscle power
-hydrotherapy for osteoarthritis of hip
• Surgery
-joint replacement and other surgical
procedures discussed in the section of
rheumatoid arthritis.
