World of Joints A look at the joint examination Pediatric Rheumatology Red Team Resident Teaching Series

Joint - Definition Joints are discontinuities in skeleton that permit mobility

Diarthrotic Joint Components Hyaline Cartilage or Diarthroses – joints that allow significant movement; –ex: knee/ elbow Synovium –Covers all intra-articular surfaces, except articulating areas of cartilage –Synovial membrane are special fibroblasts that secrete viscous ultrafiltrate and also have macrophage functions –Synovial fluid used for lubrication and nutrition

Diarthrotic Joint Components Muscles Bone Cartilage –Precursor to bone –At the ends of bone

Joint Components Tendons Ligaments Entheses connections between muscle and bone; are active drivers site of insertion into the periosteum connections between bones and bones; passive restraints

Joint Terminology Arthralgia: joint pain without abnormality Arthritis (Synovitis): Objective joint abnormality –Either joint swelling, or pain/tenderness with limitation

Arthritis: History Objective symptoms lasting minimum of 3 days in same joints Pain is usually insidious onset but can be significant enough to affect daily activities Morning stiffness – due to gelling phenomenon very common Night pain not common Can have accompanying constitutional symptoms Inflammatory vs. mechanical joint pain

Pain characterization –Site –Number of joints involved –Severity –Frequency –Duration –Pattern of pain –Exacerbating and alleviating factors –Onset: acute or insidious –At rest? –Radiation Swelling? Warmth? Discoloration? Stiffness? Arthritis: History

Pain characterization –Frequency, Duration, Pattern of pain: Persistent- JIA, infection, malignancy Intermittent- associated with activity, more likely due to mechanical problem. Migratory pain- last for several days, then resolves, while other previously unaffected joints become painful. Characteristic of ARF, PSRA, HSP, leukemia/ lymphoma Recurrent-with spontaneous resolution, may indicate Lyme arthritis, FMF or other periodic syndromes Arthritis: History

Pain characterization –Time of day Diurnal variation: JIA is worse in the morning, trauma or mechanical pain worsens with activity, growing pains usually at night, malignancy pain day or night –Rapid onset within 1-2 days: infection, vasculitis (HSP) –Insidious onset: JIA –Inflammatory (red, warm, swollen) or mechanical pain (locks, gives way) Arthritis: History

Pain characterization –Exacerbating factors: inactivity (gelling phenomenon) in JIA, physical activity worsens mechanical joint pain and growing pains –Alleviating factors: physical activity usually helps in JIA Precipitating factors: –Trauma –Antecedent infection Disability Arthritis: History

Physical Exam - Joints Inspection at rest and during movement and palpation Positioning of the joint (with pain placed in minimal pressure position) Deformity correctable or non-correctable (swan neck) Skin changes – including erythema Warmth – signs of inflammation

Swelling: Bulge sign – confined space with small fluid volume Balloon sign – pressure on one side makes a ballooning of other side Tenderness – diffuse, point, and along the joint line Physical Exam - Arthritis

Physical Exam Inspect from front of patient: –Swelling over skin changes over sternoclavicular and acromioclavicular joint site –Equal shoulder height –Muscle asymmetry –Knee and foot deformities –Extend elbows

Physical Exam Inspect from side of patient: –Loss of normal cervical and lumbar lordosis –Facial profile –Knee deformity –Lumbar spine flexibility

Physical Exam Inspect from behind the patient: –Straight spine –Similar level of iliac crests –Normal muscle bulk/symmetry –Popliteal swelling –Achilles tendon swelling –Hindfoot deformity –Lumbar spine flexibility (Schoeber’s test)

Back evaluation

Back pain: SI pain FABERE test reproduces pain at the affected SI joint

Back pain: SI pain FABERE test reproduces pain at the affected SI joint The FABERE test (Patrick test or "figure of four" test) consists of Flexion of the hip and knee, with ABduction and External Rotation at the hip, so that the ankle of one leg is on top of the opposite knee (a figure four configuration). Force is applied downwards on the bent knee and the opposite hip, causing Extension at the sacroiliac joint.

Physical Exam - Gait Different phases: stance and swing Different gaits: Trendelenburg Antalgic high stepping/foot drop scissors gait/spastic diplegia

Knee Ranging Arthritis: Knee Exam

Muscle bulk and leg length evaluations

Arthritis: Clinical Evaluation Affected joints can grow faster causing leg length discrepancies Leg lengths – anterior superior iliac spine to medial malleolus

Hip Ranging Arthritis: Hip Exam

Arthritis: Ankle Exam

Entheses

Arthritis: Clinical Evaluation Local and general growth delay seen –Jaw –MCP/MTP

Extra-articular Manifestations Skin Rashes Nailfold Capillaries Eyes Muscles

Manual Muscle Testing Muscle – bulk and strength; wasting of muscles –Grading: 0-no contraction 1-visible contraction w/o movement 2-motion only with gravity eliminated 3-motion against gravity only 4-against gravity and some applied load 5-normal against significant load Used for dermatomyositis evaluation

Normal Nailfolds

UVEITIS with synechiae

Band Keratopathy

Reactive arthritis: conjunctivitis Iritis