Applied

Rheumatology
ANATOMY OF JOINTS, GENERAL CONSIDERATIONS, AND PRINCIPLES OF JOINT EXAMINATION 5

swollen synovial tissue (synovial membrane inflammation = Diagram for Recording Joint Disease Activity
synovitis) provides the clinician with definitive evidence of
the presence of arthritis. Swelling due to bony enlargement
(osteophytes) is also an extremely important physical find-
ing, indicating the presence of underlying primary or sec-
ondary osteoarthritis.
Crepitus refers to a “grating” sensation felt under the
examiner’s hand during joint movements, and it may indi-
cate roughening of the cartilaginous surface (cartilaginous

Made Simple
crepitus) or complete loss of hyaline cartilage with bone-on-
bone contact (bony crepitus).
Joint damage and deformity are important, usually perma-
nent, signs of prior injury (ligamentous laxity, tendon rupture,
flexion contracture) or arthritis (ulnar deviation, subluxation).
The pattern of such damage and deformity can provide impor-
tant clinical clues to the underlying process.
Manual muscle testing is an important part of the physi-
cal examination of musculoskeletal conditions. Careful
evaluation of muscle length and strength provides valuable
information regarding diagnosis, the focus of rehabilitation,

(A.R.M.S.)
and a basis for determining progress. The art and science of
manual muscle testing involves specific positioning to isolate
a muscle, test it in its shortest position, and grade its strength
on a scale from 0 to 5. For instance, grade 3 strength means
the patient can hold the test position against gravity but not
with any other pressure applied. Manual muscle testing is
the tool of choice for evaluating muscle imbalances.
EXAMINATION COMPONENTS
There are four essential steps in the examination of joints:
inspection, palpation, active and passive range of motion, and the
assessment of supporting structures and special testing. Inspect
the joint for asymmetry, erythema, swelling, and deformity.
Palpate for tenderness; warmth; synovial thickening; effusion
(in inflammatory synovitis); bony, osteophytic swelling (in
primary and secondary osteoarthritis); and crepitus. Take
the joint through a combination of active (patient-initiated)
and passive (examiner-initiated) range-of-motion tests
appropriate to the specific joint. Finally, assess supporting
structures—such as ligaments, tendons, and muscles—and
perform special testing using regional evaluations specific to
particular joints. Examples of special testing include manual
muscle testing, impingement testing (shoulder), and testing
for Tinel sign (entrapment neuropathies).
FIGURE 1-3 DIAGRAM FOR RECORDING MUSCULOSKELETAL EXAM
FINDINGS.
UE: multiple Heberden nodes; mild tenderness and cool
swelling; R second and fourth and L fifth PIPs; sublux-
ation and “squaring” of first CMCs; nontender acro-
mioclavicular osteophytes.
LE: R hip: flexion 90°, ER 40°, IR 10° with groin pain at
end IR; L hip: flexion 120°, ER 60°, IR 40° and painless;
bilateral hallux valgus.
C SPINE: mild ↓ flexion; 40° R and L rotation; ↓↓ exten-
sion with mild pain posteriorly.
LS SPINE: full flexion; ↓ lateral bend; ↓↓ extension with
pain at lumbosacral junction without radiation.
GAIT: antalgic gait with R groin discomfort.
Use of cartoon diagrams to record findings can also be quite
helpful (Figure 1-3).
SELECTED READINGS
Agur, A.A., Dalley, A.F., 2004. Grant’s Atlas of Anatomy, eleventh ed.
Lippincott Williams & Wilkins, Philadelphia.
Grant, J.C.B., 1989. Grant’s Method of Anatomy: A Clinical Problem-

Deske Muhadi
Recording Exam Findings
A brief record of abnormalities can be made by organiz-
Solving Approach, eleventh ed. Lippincott Williams & Wilkins,
Philadelphia.
Griffin, L.Y. (Ed.), 2005. Essentials of Musculoskeletal Care, third ed.
American Academy of Orthopedic Surgeons, Rosemont, IL.
Internal Medicine Rheumatology
ing your examination into the following categories: upper
extremities (fingers, wrists, elbows, and shoulders); lower
extremities (hips, knees, ankles, and feet); spine (cervical,
Hoppenfeld, S., 1976. Physical Examination of the Spine and Extremities.
Appleton-Century-Crofts, New York.
Kendall, F.P., 2005. Muscle Testing and Function, fifth ed. Lippincott

Medical Faculty of Sumatera Utara (USU)

thoracic, lumbosacral, and sacroiliac joints); and gait (not-
ing uneven rhythm, limp, and asymmetry). Abnormalities
such as tenderness, swelling, altered range of motion, and
deformity can then be easily reviewed and compared by sub-
sequent examiners.
For example, a patient with significant generalized, primary
osteoarthritis might have a joint examination record as follows:
Williams & Wilkins, Philadelphia.
Klippel, J.H. (Ed.), 2008. Primer on the Rheumatic Diseases, thirteenth ed.
Springer-Arthritis Foundation, Atlanta, GA.
Sahrmann, S.A., 2002. Movement Impairment Syndromes. Mosby,
St. Louis.
Weinstein, S.L., Buckwalter, J.A., 2005. Turek’s Orthopedics, sixth ed.
JB Lippincott, Philadelphia.
RHEUMATIC DISEASES COMMONLY SEEN
IN PRIMARY CARE PRACTICE

•  Soft tissue rheumatism

•  Osteoarthritis
•  Rheumatoid arthritis
•  Gout
•  Systemic lupus erythematosus
•  Septic arthritis
•  Juvenile rheumatoid arthritis
•  Ankylosing spondylitis
•  Psoriatic arthritis
•  Scleroderma
•  Henoch-Schonlein purpura
THE 3-MINUTE MUSCULOSKELETAL EXAM

G ait
A rms
L egs
S pine
ACRFP
KEY QUESTIONS

Do you have pain or stiffness in your joints or

spine?

Do you have difficulties with walking, climbing

stairs or getting up from bed?

Do you have difficulties with dressing?

 Osteokinematic movement
terminology
8 SECTION I Principles and Methods

Neck
rotation
Neck Neck
extension flexion
Neck side
flexion
Trunk
Trunk flexion
extension
Trunk side
flexion
Shoulder
external
rotation
Elbow
flexion Shoulder
internal
rotation

Wrist Shoulder Shoulder

radial adduction abduction
deviation
Elbow
extension
Hip
extension Hip Hip
flexion external
Finger rotation
abduction
Knee
extension

Hip
Ankle internal
Knee dorsiflexion rotation
flexion
Hip
abduction
Hip
adduction
Ankle
plantarflexion
 CHAPTER 1 Principles and Methods 27

Examples of recording range

of motion (ROM) using a
pictorial recording form: (A)
right shoulder flexion and
extension, (B) right elbow
flexion and extension/
A
hyperextension, and (C) left
hip internal and external
C rotation. The use of shading
to show the available elbow
flexion ROM is illustrated in B

Figure 1-46 Examples of recording range of motion (ROM) using a pictorial recording form: (A) right shoulder flexion and extension, (B)
right elbow flexion and extension/hyperextension, and (C) left hip internal and external rotation. The use of shading to show the available
elbow flexion ROM is illustrated in B.
 212
Musculoskeletal Complaint

Initial rheumatic history and physical

exam to determine
1. Is it articular?
2. Is it acute or chronic?
3. Is inflammation present?
4. How many/which joints are involved?

Nonarticular condition
Consider
No Is it articular? Algorithm for the diagnosis of
Yes
• Trauma/fracture
• Fibromyalgia
musculoskeletal
ANATOMY OF JOINTS, GENERAL CONSIDERATIONS, complaints.
AND PRINCIPLES OF JOINT EXAMINATION
Is complaint > 6 wk?
• Polymyalgia rheumatica
• Bursitis No Yes
swollen synovial tissue (synovial
• Tendinitis
membrane inflammation = Diagram for Recording Joint Disease Activity
synovitis) provides the Acute clinician withChronic definitive evidence of
the presence of arthritis. Swelling due to bony enlargement
(osteophytes) is also an extremely important
Is inflammation present? physical find-
SECTION III

Consider 1. Is there prolonged morning stiffness?

• Acuteing, indicating the presence 2.ofIs underlying
arthritis primary or sec-
there soft tissue swelling?
ondary
• Infectious
• Gout
osteoarthritis.
arthritis 3. Are there systemic symptoms?
4. Is the ESR or CRP elevated?
Crepitus refers to a “grating”
• Pseudogout sensation felt under the
• Reactive arthritis No Yes
examiner’s hand during joint movements, and it may indi-
• Initial presentation
cate arthritis
of chronic roughening of the cartilaginous
Chronic Chronic surface (cartilaginous
How many
crepitus) or complete noninflammatory inflammatory
loss of hyaline cartilage with bone-on-
joints involved?
Disorders of the Joints and Adjacent Tissues

arthritis arthritis
bone contact (bony crepitus).
1– 3 >3
Joint damage and deformity are important, usually perma-
nent, signs of prior injury (ligamentous
Are DIP, CMC1, hip or
laxity, tendonChronic
Chronic inflammatory rupture,
inflammatory
mono/oligoarthritis polyarthritis
flexion contracture) orinvolved?
knee joints arthritis (ulnar Consider deviation, subluxation).
The pattern of such damage and deformity can provide Isimpor-
• Indolent infection FIGURE 17-1
involvement
tant clinical cluesNo to theYes underlying • Psoriatic arthritis
process. symmetric? Algorithm for the diagnosis of
• Reactive arthritis
musculoskeletal complaints. An
Manual muscle testing is an important • Pauciarticular JA part of the No physi-Yes
Unlikely toexamination
be osteoarthritis
approach to formulating a differential
cal
Consider
of musculoskeletal
Osteoarthritis conditions. Careful diagnosis (shown in italics). (ESR,
Consider Are PIP, MCP, or
evaluation of muscle length and strength
• Osteonecrosis provides
• Psoriatic arthritis valuable MTP joints erythrocyte sedimentation rate; CRP,
• Charcot arthritis
information regarding diagnosis, the focus of rehabilitation, • Reactive arthritis involved?
C-reactive protein; DIP, distal inter-
and a basis for determining progress. The art and science No of Yes phalangeal; CMC, carpometacarpal;
manual muscle testing involves specific positioning to isolate
Unlikely to be rheumatoid arthritis Rheumatoid
PIP, proximal interphalangeal; MCP,
a muscle, test it in its shortest position, Consider
• SLE
and grade its strengtharthritis FIGUREmetacarpophalangeal;
1-3 DIAGRAM
MTP, metatar-
FOR polymyalgia
RECORDING MUSCULOSKELETAL EXA
on a scale from 0 to 5. For instance, • Sclerodermagrade 3 strength means sophalangeal; PMR,
• Polymyositis FINDINGS.
rheumatica; SLE,
John J Crush et al,systemic lupus
Herrison Rheumatology 2nd Ed; 2010
the patient can hold the test position against gravity but not erythematosus; JA, juvenile arthritis.)
 216 is suggested by
and may be co
taining the wri
the digits distal
sor tendon shea
DIP: OA, Focal wrist p
psoriatic,
reactive
caused by De
inflammation of
PIP: OA, SLE, tor pollicis long
RA, psoriatic This commonly
and may be dia
MCP: RA,
pseudogout,
result is present
hemochromatosis thumb is flexed
1st CMC: OA
patient actively
deviation at the
Wrist: RA,
common disord
De Quervain's pseudogout, compression of
SECTION III

tenosynovitis gonococcal arthritis, nel. Manifestatio

juvenile arthritis, ond and third fi
carpal tunnel syndrome
and, at times, atr
syndrome is com
FIGURE 17-4 trauma, OA, infl
Sites of hand or wrist involvement and their potential ders (e.g., amyl
disease associations. (DIP, distal interphalangeal; OA,
D
 218 Anterior Posterior/lateral

Sacroiliac pain

Enthesitis Buttock pain

(anterior superior referred from
iliac crest) lumbosacral
spine
True hip pain
lliopsoasbursitis Trochanteric
bursitis
Ischiogluteal
Meralgia bursitis
paresthetica
Sciatica

FIGUR
Origins
(From C
SECTION
 SOFT TISSUE RHEUMATISM
bone skin & subcutaneous
tissue
capsule bursa
enthesis
synovium tendon sheath
fibrocartilage tendon
pad muscle
joint space ligamentous
thickening
hyaline articular of capsule
cartilage bursa
SOFT TISSUE RHEUMATISM

Tendonitis
Bursitis
Muscular strain / Myofascial pain
 CAUSES OF SOFT TISSUE
RHEUMATISM

Overuse or injury
Incorrect posture
Structural abnormalities e.g. polio, scoliosis
Associated with arthritides e.g. RA, gout, OA
Occasionally from an infection
Very often unknown
STENOSING TENOSYNOVITIS
DE QUERVAIN’S
TENOSYNOVITIS
CARPAL TUNNEL SYNDROME
LATERAL EPICONDYLITIS
 SHOULDER PAIN SYNDROMES
Supraspinatus Clavicle
muscle
Acromion
Glenohumeral
fossa Coracoacromial
ligament
Subacromial Coracoid
bursa process
Lesser Subscapular
tubercle fossa
Greater Intertubercular
tubercle synovial sheath
Intertubercular Humerus
groove Scapula
Deltoid
muscle
ACRFP
Anterior aspect of the shoulder joint
SHOULDER PAIN SYNDROMES

Impingement syndrome (rotator cuff tendonitis)

Subacromial tendonitis
Bicipital tendonitis
Myofascial pain
HIP PAIN SYNDROMES

Trochanteric bursitis
•  Pain in the greater
trochanter region
•  Local tenderness over
lateral hip area
•  Calcification of bursa
may occur

ACRFP
KNEE PAIN SYNDROMES
Quadriceps femoris
muscle
Gastrocnemius muscle Suprapatellar
(medial head) bursa
Semimembranosus bursa Quadriceps
communicating with joint tendon
space
Prepatellar
Gastrocnemius bursa bursa
communicating with Infrapatellar
joint space bursa
Medial collateral lig. Superficial & deep
Anserine bursa Infrapatellar bursa
ANKLE and FOOT PAIN
SYNDROMES Achilles
medial and lateral tendon
subcutaneous malleolar
or last bursa retrocalcaneal
bursa

retroachilleal
bursa

ACRFP

plantar aponeurosis subcalcaneal bursa

 ANKLE and FOOT PAIN
SYNDROMES

Achilles tendonitis
Calcaneal bursitis
Plantar fasciitis
MANAGEMENT OF SOFT TISSUE
RHEUMATISM

Rest during the acute phase

Splints, bands, soft pads etc.
Heat and/or cold applications
Physical therapy
Medications e.g. NSAIDs, analgesics
(systemic and topical)
Prevention e.g. exercises, avoid repetitive
motion, weight reduction
ARTHRITIS RUSH
SYNDROME
Conjunctivitis in Reiter’s syndrome
Maculopapules on
the trunk in Reiter’s
syndrome
Circinate balanitis in Reiter’s syndrome. Keratoderma blennorrhagica in Reiter’s syndrome. In
addition to the triad of arthritis-conjunctivitis-urethritis (and
the characteristic rashes) in classical Reiter’s, some
patients may present with gastrointestinal symptoms of
diarrhea with or without urethritis
Psoriatic arthritis characteristically presents as scaly rashes, onycholysis, and
asymmetric oligo- or poly-arthritis. The classic presentation depicted in the slide
is less frequently seen than patients who may just complain of arthritis, unaware
of its association with a remote scaly patch (or excessive dandruff).
Henoch Schönlein purpura commonly presents in childhood and adolescence (less frequently
in adults) as purpuric lesions (usually on the lower extremities), arthritis, occasional abdominal
pain, and nephritis. This is best referred to the specialist who may need to screen and monitor
for complications.
Systemic lupus
erythematosus (SLE) is now
more commonly reported
among Asian people than
it was 20-30 years ago. This
is a disease with a myriad
of potential
manifestations ranging
from mild to severe/life-
threatening. SLE is also
best referred to the
specialist for
recommendations on
long-term management
and monitoring.
 Jacoud-type arthropathy

Periungal erythema with nailfold

vasculitis

Livedo reticularis
 EULAR Textbook on Rheumatic Diseases
The American College of Rheumatology revised classification criteria for systemic lupus erythematosus 1997

Criteria Definition
Malar rash Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
Discoid rash Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic
scarring occurs in older lesions
Photosensitivity Skin rash as a result of unusual reaction to sunlight, by patient history or physician
observation
Oral ulcers Oral or nasopharyngeal ulceration, usually painless, observed by a physician
Arthritis Non-erosive arthritis involving two or more peripheral joints, characterised by tenderness,
swelling or effusion
Serositis a. Pleuritis: convincing history of pleuritic pain or rub heard by a physician or evidence of
pleural effusion or
b. Pericarditis: documented by ECG or rub or evidence of pericardial effusion
Renal disorder a. Persistent proteinuria >0.5 g per day or >3+ if quantitation is not performed or
b. Cellular casts: may be red cell, haemoglobin, granular tubular, or mixed
Neurological disorder a. Seizures: in the absence of offending drugs or known metabolic derangements (eg, uraemia,
acidosis, or electrolyte imbalance) or
b. Psychosis: in the absence of offending drugs or known metabolic derangements
(eg, uraemia, acidosis, or electrolyte imbalance)
Haematologic disorder a. Haemolytic anaemia with reticulocytosis, or
b. Leucopenia: <4000/mm3, or
c. Lymphopenia: <1500/mm3, or
d. Thrombocytopenia: <100 000/mm3 in the absence of offending drugs
Immunologic disorder a. Anti-DNA: antibody to native DNA in abnormal titre, or
b. Anti-Sm: presence of antibody to Sm nuclear antigen, or
c. Positive finding of antiphospholipid antibodies based on: (1) an abnormal serum
concentration of IgG or IgM anticardiolipin antibodies, (2) a positive test result for lupus
anticoagulant using a standard method, or (3) a false positive serologic test for syphilis
known to be positive for at least 6 months and confirmed by Treponema pallidum
immobilisation or fluorescent treponemal antibody absorption test
Antinuclear antibody An abnormal titre of antinuclear antibody by immunofluorescence or an equivalent assay at
any point in time and in the absence of drugs known to be associated with ‘drug-induced
lupus’ syndrome
EULAR Textbook on Rheumatic Diseases

Item Score Item Score

Ocular (either eye by clinical assessment) Peripheral vascular
Any cataract ever 0, 1 Claudication for 6 months 0, 1
Retinal change or optic atrophy 0, 1 Minor tissue loss (pulp space) 0, 1
Neuropsychiatric Significant tissue loss ever (eg, loss of digit or 0, 1, 2
Cognitive impairment (eg, memory deficit, 0, 1 limb) (score 2 if >1 site)
difficulty with calculation, poor Venous thrombosis with swelling, ulceration or 0, 1
concentration, difficulty in spoken or venous stasis
written language, impaired performance Gastrointestinal
level) or major psychosis
Infarction or resection of bowel below
Seizures requiring therapy for 6 months 0, 1 duodenum, spleen, liver or gallbladder ever, for 0, 1, 2
Cerebrovascular accident ever (score 2 if >1) 0, 1, 2 any cause (score 2 if >1 site)
Cranial or peripheral neuropathy (excluding 0, 1 Mesenteric insufficiency 0, 1
optic) Chronic peritonitis 0, 1 The Systemic Lupus
Transverse myelitis 0, 1 Stricture or upper gastrointestinal tract surgery 0, 1 International
Renal ever
Estimated or measured glomerular filtration 0, 1 Chronic pancreatitis 0, 1
Collaborating
rate <50% Musculoskeletal Clinics/American
Proteinuria >3.5 g/24 h 0, 1 Muscle atrophy or weakness 0, 1 College of
or end-stage renal disease (regardless of dialysis or 3 Deforming or erosive arthritis (including 0, 1
or transplantation) reversible deformities, excluding avascular Rheumatology
Pulmonary necrosis) (SLICC/ACR)
Osteoporosis with fracture or vertebral collapse 0, 1
Pulmonary hypertension (right ventricular
prominence, or loud P2)
0, 1
(excluding avascular necrosis) Damage Index for
Pulmonary fibrosis (physical and 0, 1 Avascular necrosis (score 2 if >1) 0, 1, 2 systemic lupus
radiographical) Osteomyelitis 0, 1 erythematosus
Shrinking lung (radiograph) 0, 1 Tendon rupture 0, 1
Pleural fibrosis (radiograph) 0, 1 Skin
Pulmonary infarction (radiograph) 0, 1 Scarring chronic alopecia 0, 1
Cardiovascular Extensive scarring of panniculum other than 0, 1
Angina or coronary artery bypass 0, 1 scalp and pulp space
Myocardial infarction ever (score 2 if >1) 0, 1, 2 Skin ulceration (excluding thrombosis for >6 0, 1
months)
Cardiomyopathy (ventricular dysfunction) 0, 1
Premature gonadal failure 0, 1
Valvular disease (diastolic murmur, or systolic 0, 1
murmur >3/6) Diabetes (regardless of treatment) 0, 1
Pericarditis for 6 months or pericardiectomy 0, 1 Malignancy (exclude dysplasia) (score 2 if >1 site) 0, 1
Scleroderma is usually initially recognized by the classical skin
tautness. This is best referred to the specialist for appropriate work-up
and management
Polymyositis – dermatomyositis
usually presents with proximal
muscle weakness.
Characteristic rashes, if
present, include a heliotrope
rash on the eyelid, Gottron’s
patches over the knuckles and
other maculopapules usually
located on the chest and
face. This is best referred to the
specialist for appropriate work-
up and management.
DIAGNOSTIC CLUES FROM BASIC
LABORATORY TESTS
•  Complete Blood Count
– Anemia (& thrombocytopenia) - SLE, vasculitides
– Leucopenia - SLE
•  Erythrocyte sedimentation rate
– Elevated - usually in all
•  Urinalysis
– Pyuria - Reiter s
– Proteinuria, hematuria, cylindruria - SLE,
HSP
ACRFP
OTHER LABORATORY TESTS
•  Azotemia - poor prognosis in SLE,
vasculitides
•  ALT, AST elevation - hepatitis or
myositis
•  Hypocomplementemia - SLE

ACRFP
The deforming polyarticular involvement of RA
NORMAL vs. RA SYNOVIUM
Normal Rheumatoid Synovitis
bursitis cartilage

bone lining cell

hyperplasia
tendonitis pannus
polymorph
exudate
synovitis mononuclear
infiltrate
fibrosis

monocyte ACRFP
 pain over the radial styloid is a positive finding, often indi- do not interfere with assessment of the synovial membrane.
cating stretching of the thumb tendons in a stenosed tendon Alternatively, the joint can be compressed anteroposteriorly
sheath. by the thumb and index finger of one of the examiner’s
ORY AND PHYSICAL EXAMINATION OF THE MUSCULOSKELETAL
Carpal tunnel syndrome results from pressure on the SYSTEM 567
median nerve in the carpal tunnel. Carpal tunnel syndrome
is discussed in detail in Chapter 50.
e for
Muscle function of the wrist may be measured by testing
test flexion and extension and supination and pronation of the
nter- forearm. The principal flexors of the wrist are the flexor
scles carpi radialis (nerve roots C6 and C7) and flexor carpi
ulnaris (C8 and T1) muscles. Each of these muscles can be
peri- tested separately. This testing can be accomplished if the
sym- examiner provides resistance to flexion at the base of the
cular second metacarpal bone in the direction of extension and
joint ulnar deviation in the case of the flexor carpi radialis muscle
de of and resistance at the base of the fifth metacarpal in the
es an direction of extension and radial deviation in the case of
digit, the flexor carpi ulnaris muscle. The principal extensors of
esult the wrist are the extensor carpi radialis longus (C6 and C7),
the extensor carpi radialis brevis (C6 and C7), and extensor
iatic carpi ulnaris (C7 and C8) muscles. The radial and ulnar
well- extensor muscles can be tested separately. The principal
nces supinators
Figure 40-5of the
5 forearm
Swan are the biceps
neck deformity brachii
in a patient with(C5 arthritis. Figure
andLOCALIZED
psoriaticC6) 40-3 Palpation
Palpation of the metacarpophalangeal joints
of the metacarpophalangeal joints is done
is done with
well- and
566
Note Swan PART neck
hyperextension
supinator
| deformity
EVALUATION OF GENERALIZED
of the proximal
(C6) muscles. interphalangeal
The principal
AND
joint and
pronators hyper- the
of the
SYMPTOMS
examiner’s thumbs palpating the dorsal aspect of the joint, while the
with the examiner’s thumbs palpating the dorsal
flexion of the distal interphalangeal joint of the second digit. Also note forefingers palpate the volar aspect of the metacarpal head. The joints
oints forearm are the pronator teres (C6 and C7) and pronator
the psoriatic changes of the third and fourth fingernails. aspect
should of the joint,
be examined while while the fore
the examiner holdsngers palpate
the patient’s handthe
in a
cular quadratus (C8 and T1) muscles. volarposition
relaxed aspect of of theflexion.
partial metacarpal head. The joints should
uscle Metacarpophalangeal and Proximal and Distal
be examined while the examiner holds the patient’s
xten- interphalangeal joint becomes detached from the base of hand Interphalangeal Joints
in a relaxed position of partial exion.
eads the middle phalanx, allowing palmar dislocation of the The metacarpophalangeal joints are hinge joints. Lateral
the lateral bands. The dislocated bands cross the fulcrum of the collateral ligaments that are loose in extension tighten in
ulnar joint and act as flexors instead of extensors of the joint. flexion, preventing lateral movement of the digits. The
hritis Another abnormality is telescoping or shortening of the extensor tendons that cross the dorsum of each joint
digits produced by resorption of the ends of the phalanges Subluxation strengthen the ofarticular
the wrist. SideWhen the extensor tendon
capsule.
xion secondary to destructive arthropathy. This may be seen in view of the wrist of a patient
of the digit reaches the distal end of the metacarpal head,
xten- the arthritis mutilans form of psoriatic arthritis. Shortening
of the fingers is associated with wrinkling of the skin over with rheumatoid arthritis. Note
n of
it is joined by fibers of the interossei and lumbricales muscles
pro- involved joints and is called opera-glass hand or la main en the and expands over the
prominence entire
of the dorsum of the metacarpopha-
ulna.
scles lorgnette. langeal joint and onto the dorsum of the adjacent phalanx.
the A mallet finger results from avulsion or rupture of the This expansion of the extensor mechanism is known as the
Spine radiograph of a patient with ankylosing spondylitis illustrating the classical
syndesmophytes ,“dagger sign” of calcified paraspinal ligaments, and osteopenia
associated with chronic inflammatory diseases
Terima kasih