RA OF HAND

Swelling of PIP Joints
DIP Joints look Normal
Polyarthritis (at least Oligo)

Not be gout unless having gout for 15-20 years
If squeezed on it, may be soft..."boggy"...soft tissue swelling. 
If were told that MCP joints were involved as well, think that this would be a common presentation or RA or its 1st cousin SLE

RA PROGRESSION

1) RA is a disease of synovial inflammation (like that hand with fingers picture).  Soft tissue swelling and inflammation in synovium, and if it progresses...NEXT

2) If it progresses...that inflam tissue invades out across the cartilages and causes loss of the cartilages, again with even more swelling.  Behaves like an inflammatory tumor as it were

3) Hypertophied villous inflam tissue invade and destroy cartialge...eventually producing THIS kind of joint...If look at inflamed tissue histologically, it looks Villous, all filled with lymphocytes, Plasma cells, etcs...in some, may even appear like follicles because so chronic and severe...

RA PROGRESSION

A) MCP joint occupied by joint space.  Bones not touching because cartilage (doesn't appear)

B) Year or two later.  Narrowing across joint of cartilage.  Not as well ossified cortex of bone on the side there

C) Years later.  Bone is rubbing against bone with erosiions/cysts down below, and a chewed out bite as result of inflam tissue invading joint over the years

RA-SEVERE

RA Again if BAD.  Upper MCP (2nd/3rd) and both knees and entire metatarsal phalyngeal row. 

RA is an inflammatory, polyarthritis of Upper and Lower Extrimity Large and Small Joints

May just start in one place and involved other joints.  But this would be a classic presentation

SLE would present the same way.

-Classical pattern for the Spondyloarthropathies
-Any individual joint will look like RA, but pattern suggest it is NOT (NOT symmetrical, but is upper and lower.)

OSTEOARTHRITIS-HANDS

-Some rubor in tips (typically NOT MUCH redness)
-Tumor
-Loss of function
-If take pt's right index finger, looks BONY and Hard

This is another polyarthritis, it is a great picture for PRIMARY NODAL OSTEOARTHRITIS

The swelling here is bony/fibrous. and not much redness (not really inflam, but some people can have a component that is inflam).  Typically see it in the DIP joints and then classically back in the carpal-metacarpal joints (where back of hand, can see it sqaurin off a bit on right hand where bump is.  If advances, the metacarpal bone of thumb, the back end will back out, and get squaring off in rear, and front of hand squared as well..."spade like hand...squaring off like square spade" Also see some subluxing out

OSTEOARTHRITIS

This would be a fairly typical pattern of the dominant hand
You see the first carpal-metacarpal squaring off and causing pain
-the DIP joints comonly involved
-the Knees because are weight bearing (it is a wear and tear Arthritis)

OSTEOARTHRITIS PROGRESSION
1) Not inflammatory of synovium
-Minimal morning stiffness
-Evenings are Worse, Worse with use
-Cartilage wears away, but not evenly like w/inflammation, wears away because of pressure and use, so get asymmetrical joint space narrowing

2) OSTEOARTHRITIS WORSENING
-Eventually get Osteophytes (can see that on our right on the bottom bone)
-Again, no inflam of synovium
-The Right side of joint, the cartilage is all worn away, but some remained on our left side

3) OSTEOARTHRITIS END STAGE

OSTEOARTHRITIS X-RAY OF KNEE JOINT
**This differs from RA knee joint we saw.
-look at persons right knee.  And notice how nice the joint space is laterally.  But there is bone rubbing against bone medially.  Furthermore, look at the amount of bone sclerosis. 

-Look at person's left knee.  They have deformaties.  Lateral compartemtn is bone on bone, lots of sclerosis, and pretty normal joint space on other side. 

*So osteoarthritis shows REGIONAL wearing away and SCLEROSIS way of proportion to what you see with joint space narrowing....this is in CONTRAST to RA or other inflam

TESTING FOR HIP FLEXION CONTRACTURES

A contracture means that it doesn't move out to the spot it doesn't move to.
20 flexion contracture of elbow means that as start to extend elbow, when get to 20 degrees of flexion it stops, and it shouldn't, it should come all the way out to zero
Record that as extension is -20, that means the patient lacks 20 degrees of full extension

Same with the knee.  IF knee normally comes out to 0 degrees with extension. and you have arthritis in one knee and can only get it to 20 degrees, and beyond that can't extend it out any further, then you have a 20 degree flexion contracture, or -20 degrees of extension.

Hips can be contracted, and look like they are perfectly striaght at 0 degrees.  The reason is beause you tend to cheat.  If you have Arthritis in one hip, and it could be very difficult to detect.  Pt could be lying flat, and actually have a 20-30 degree flexion contracture of hip (hip is not fully extended), it is bent, but they hyperextend their lumbar spine to get it straight.  You detect this on examining table by bringing the other hip up, and bring it up so far that it flattens out the lumbar spine.  Put your hand underneath to feel their spine come back down on your hand.  Then you look to see if their thigh pulls up off that table.

The back pays a price if this occurs over long time (at Fascet Joints, post joints at each vertebral level) About 8 years later he would feel buttock pain, with back being a problem.  Also see this in kids who have had Juvenile RA. 

1) LEFT IS VALGUS: Knock knee.  Tibia is lateral to where it should be, has a L in it.

2) RIGHT IS VARUS: Bow legged.  If put femur in anatomical positon in our head, the tibia is medial to where it should be, and that is Varus

Lordosis: Concavity to rear
Kyphosis: Concavity to front

-Lordosis common in lumbar, cervical spine, and where you get most of herniated disks because vertebral bodies are squeezing disks out as you get older
-Normal Kyphosis to dorsal spine (somewhat)

C SHAPED (PARALYTIC) SCOLIOSIS

Normally paravertebral muscles on R and L are equally tight, and maintian in "tent pole" straight.  If for some reason muscles on one side are weak (ex paralyzed from stroke), the other side will dominate, and pull it over in that direction.

INHERITED KYPHOSCOLIOSIS

More common Sciolosis.  Starts to be picked up in adolescence.  They tested you to bend over and touch toes, and observor was behind you.  They were looking to see if you might rotate (esp if right scapula is higher than left, because vertebral bodies are rotating on top of each other...right up and left down).  The vertebral bodies are rotating one on top of other.  If problem is NOT fixed, the ribcage can twist, compress right lung, and compress heart, and get heart problems.  Look shorter from waist up because rotation has cause ribcage to hump up on back, and the hump, which is not the spine, but is the right ribcage.

CERVICAL SPINE
-does all of these motions fairly well.  Good because all of our sensors are on our head
-Can rotate cervical spine 80 or 90 degrees to right
-Lateral bending  60-70 degrees normal
-Extension hard to measure, just record as normal, impaired etc
-Flexion: Put chin on chest.  Can get it about about 45 degrees
*What you lose first is lateral bending when get older.  With early osteoarthritis of neck, will lose that motion first.  About 1/2 ppl with shoulder problems actually have cervical radiculopathy referred to shoulder

THORACIC SPINE
-Flexes and Extends the least
-Lateral bending can go on in any level of spine, but tends to be little less in upper/mid thoracic
-Don't really measure these two main movements
-Rotation is measured
-Spondyloarthropathies can fuse the thoracic spine.  Have pt sit on table, and have them twist so they don't cheat with hips.  Should get 30 degrees, but those pts might get only 0 degrees.

LUMBAR SPINE
-Rotation is limited in Lumbar Spine

LUMBOSACRAL ROOT DISEASE

Depending where it is, get different pains radiating in different areas.

The most common presenting manifestation of lumbosacral root disease is buttock pain.

NOT GOING TO GO INTO THIS...BUT

If disk going to get L4, Will be L4/L5 disk that will trap it

SCHOBER'S TEST

1) Measure of flexion
2) Those dots are his Posterior Superio Iliac Spines
3) Make another mark up 10 cms
4) Bend pt away from you, and see if line lengthens 1.5 cm or more
5) If it does, he has adequate flexion of lumbar spine
6) If it does not, he is not flexing spine well: Spasm, tumor, disk, etc...not sure of etiology

TRENDELENBURG

Here is the fulcrum.  When left leg is off ground. this hip is bearing all weight of body.  This is not a symmetrical see saw.  The entire weight is exerted out spine.  If can't keep see saw level, it will fall over when pick leg up unless can push with the equivalent amount of force/torque on the other side.  If have 200 lbs up here, and 25 lbs in leg, have 225 lbs there.  Have to put 3x more weight on other side to balance that see-saw.  You get that amount of lbs by gluteal muscles which insert on trochanter, and they pull down with 675 lbs to counter that. 

At this point, 900 lbs is on that fulcrum.  If you can slide that 225 lbs on top of the trochanter (on top of the fulcrum), You only have 225 lbs on the fulcrum (roughly a fourth).  How do you do that?  You Trendelenberg.  You push weight of the other side of the body on top of the hip joint.  People do this because their gluteal muscle is usually too weak to pull with 675 lbs.  That will happen with somebody who has had Polio or a paralytic illness that has only affected one side. 

If have painful hip, (RA or OSTEO) that is when you have Antalgic Gait with Trendelenberg, because by reducing the weight there, it causes less pain.

You can get Trendelenberg gaits with fascet joints with lever, if have short lever arm with paravertebrals pulling down on side, so you can get Trendelenberg gaits with fascet arthritis as well

You can see someone with Bilateral Trendelenberg gait, not Antalgic.  They are big fat people.  They are shifting weight around, because gluteals just don't have the power the pull the gluteals around on both side.