The rheumatological system

Chapter 9 The rheumatological system




Rheumatology is ‘the study of the Rheumatic Diseases including arthritis, rheumatic fever, fibrositis, neuralgia, myositis, bursitis, gout and other conditions producing somatic pain, stiffness and soreness’ (Oxford English Dictionary, 2nd edn, 1989). The rheumatological system therefore includes diseases of the joints, tendons and muscles.



The rheumatological history



Presenting symptoms (Table 9.1)



Peripheral joints



Pain and swelling


The underlying aetiology of joint pain can often be determined by establishing the distribution and duration of joint involvement. Remember, arthralgia is the presence of joint pain without swelling, while with arthritis there is usually pain and swelling. Determine whether one or many joints are involved.


TABLE 9.1 Rheumatological history—major symptoms



























It is often useful to ask the patient to point to the painful place or area. For example, pain said to affect the knee may be in the popliteal fossa, the knee joint itself, or in the supra- or infra-patellar bursa. Remember also that pain in the knee or lower thigh may be referred from the hip (Figure 9.1).




Find out if the symptoms are of an acute or chronic nature and whether they are getting better or worse. The effect of rest and exercise on the joint pain should be determined. Patients with rheumatoid arthritis have joint symptoms which are worse after rest, while those with osteoarthritis have pain which is worse after exercise. Ask about the sequence of onset of joint involvement. Precipitating factors such as trauma should be noted. The causes of monoarthritis (single joint) and polyarthritis (more than one joint), and the patterns of polyarthritis in various diseases, are presented in Tables 9.2, 9.3 and 9.4.


TABLE 9.2 Causes of monoarthritis







A single hot red swollen joint (acute monoarthritis)




A single chronic inflamed joint (chronic monoarthritis)




TABLE 9.3 Causes of polyarthritis


















TABLE 9.4 Patterns of polyarthropathy


















































Back pain


This is a very common symptom. It is most often a consequence of local musculoskeletal disease.


Ask where the pain is situated, whether it began suddenly or gradually, whether it is localised or diffuse, whether it radiates to the limbs or elsewhere, and whether the pain is aggravated by movement, coughing or straining. Musculoskeletal pain is characteristically well localised and is aggravated by movement. If there is a spinal nerve root irritation there may be pain that occurs in a dermatomal distribution. This helps to localise the level of the lesion. Diseases such as osteoporosis (with crush fractures), infiltration of carcinoma, leukaemia or myeloma may cause progressive and unremitting back pain, which is often worse at night (Table 9.6). The pain may be of sudden onset but is usually self-limiting if it results from the crush fracture of a vertebral body. In ankylosing spondylitis the pain is usually situated over the sacroiliac joints and lumbar spine, it is also worse at night and is associated with morning stiffness. The pain of ankylosing spondylitis is typically better with activity which helps distinguish it from mechanical back pain.1,2 Pain from diseases of the abdomen and chest (e.g. dissecting abdominal or thoracic aortic aneurysm) can also be referred to the back.


TABLE 9.6 Alarm features for back pain



















Age > 50 years
Cancer history
Weight loss (unexplained)
Pain on waking from sleep
Pain for longer than one month and unresponsive to simple analgesics
Fever
History of drug use by injection
Bowel or bladder dysfunction


Limb pain


This can occur from disease of the musculoskeletal system, the skin, the vascular system or the nervous system.


Musculoskeletal pain may be due to trauma or inflammation. Muscle disease such as polymyositis can present with an aching pain in the proximal muscles around the shoulders and hips, associated with weakness. Pain and stiffness in the shoulders and hips in patients over the age of 50 years may be due to polymyalgia rheumatica. The acute or subacute onset of symptoms in multiple locations suggests an inflammatory process. Bone disease


TABLE 9.5 Functional assessment in rheumatoid arthritis


















Class Assessment
Class 1 Normal functional ability
Class 2 Ability to carry out normal activities, despite discomfort or limited mobility of one or more joints
Class 3 Ability to perform only a few of the tasks of the normal occupation or of self-care
Class 4 Complete or almost complete incapacity with the patient confined to wheelchair or to bed

such as osteomyelitis, osteomalacia, osteoporosis or tumours can cause limb pain. Inflammation of tendons (tenosynovitis) can produce local pain over the affected area.


Vascular disease may also produce pain in the limbs. Acute arterial occlusion causes severe pain of sudden onset, often with coolness or pallor. Chronic peripheral vascular disease can result in calf pain on exercise that is relieved by rest. This is called intermittent claudication. Venous thrombosis can also cause diffuse aching pain in the legs associated with swelling.


Spinal stenosis can cause pseudo-claudication—pain on walking but relieved by leaning forward.


Nerve entrapment and neuropathy can both cause limb pain which is often associated with paraesthesiae or weakness. The usual cause is synovial thickening or joint subluxation—especially for patients with rheumatoid arthritis. The vasculitis associated with the inflammatory arthropathies can also cause neuropathy leading to diffuse peripheral neuropathy or mononeuritis multiplex. Patients with chronic rheumatoid arthritis often develop subluxation of the cervical spine at the atlanto-axial joint. This is caused by erosion of the transverse ligament around the posterior aspect of the odontoid process (dens). The patient may describe shooting paraesthesiae down the arms and an occipital headache. Neck flexion leads to indentation of the cord by the dens and can cause tetraplegia or sudden death. The abnormality may be obvious on lateral X-rays of the cervical spine (Figure 9.3). Injury to peripheral nerves can result in vasomotor changes and severe limb pain. This is called causalgia. Even following amputation of a limb, phantom limb pain may develop and persist as a chronic problem.






Red eyes


The seronegative spondyloarthropathies and Behçet’sb syndrome but not rheumatoid arthritis may be complicated by iritis (eye pain with central scleral injection—a ‘red eye’—radiating out from the pupil) (see Figure 9.51, page 279). In other diseases, such as Sjögren’s, red eyes may be due to dryness, episcleritis or scleritis.





Past history


It is important to inquire about any history of trauma or surgery in the past. Similarly, a history of recent infection, including hepatitis, streptococcal pharyngitis, rubella, dysentery, gonorrhoea and tuberculosis, may be relevant to the onset of arthralgia or arthritis. A history of tick bite may indicate that the patient has Lyme disease. Inflammatory bowel disease can be associated with arthritis, as described on page 191. A history of psoriasis may indicate that the arthritis is due to psoriatic arthropathy. It is also important to inquire about any history of arthritis in childhood. The smoking history is important: rheumatoid arthritis is more common in smokers, and smoking adds to their already increased risk of cardiovascular disease.






The rheumatological examination


There are certain established ways of examining the joints and related structures3 and it is important to be aware of the numerous systemic complications of rheumatological diseases. The actual system of examination depends on the patient’s history and sometimes on the examiner noticing an abnormality on general inspection. Formal examination of all the joints is rarely part of the routine physical examination, but students should learn how to handle each joint properly and a formal examination is an important part of the evaluation of patients who present with joint symptoms or who have an established diagnosis and active symptoms. Diseases of the extra-articular soft tissues are particularly common.




Principles of joint examination


Certain general rules apply to the examination of all the joints and they can be summarised as: look, feel, move, measure, and compare with the opposite side.



Look


The first principle is always to compare right with left. Remember that joints are three-dimensional structures and need to be inspected from the front, the back and the sides. The skin is inspected for erythema indicating underlying inflammation and suggesting active, intense arthritis or infection, atrophy suggesting chronic underlying disease, scars indicating previous operations such as tendon repairs or joint replacements, and rashes. For example, psoriasis is associated with a rash and polyarthritis (inflammation of more than one joint). The psoriatic rash consists of scaling erythematous plaques on extensor surfaces. The nails are often also affected (page 252). Also look for a vasculitic skin rash (inflammation of the blood vessels of the skin), which can range in appearance from palpable purpura or livedo reticularis (bluish-purple streaks in a net-like pattern) to skin necrosis.


A small, firm, painless swelling over the back (dorsal surface) of the wrist is usually a synovial cyst—a ganglion.c A larger, localised, soft area of swelling of the dorsum of the wrist generally indicates tenosynovitis.


Note any swelling over the joint. There are a number of possible causes: these include effusion into the joint space, hypertrophy and inflammation of the synovium (e.g. rheumatoid arthritis), or bony overgrowths at the joint margins (e.g. osteoarthritis). It may also occur when tissues around the joints become involved, as with the tendinitis or bursitis of rheumatoid arthritis. Swelling of the lower legs may be due to fluid retention, which is painless and can occur in association with inflammation anywhere in the leg. Painful swelling may result from inflammation of the ankle joints or tendons, or of the fascia, or from inflammatory oedema of the skin and subcutaneous tissue.


Deformity is the sign of a chronic, usually destructive, arthritis, and ranges from mild ulnar deviation of the metacarpophalangeal joints in early rheumatoid arthritis to the gross destruction and disorganisation of a denervated (Charcot’sd) joint (Figure 10.20, page 319). Deviation of the part of the body away from the midline is called valgus deformity, and towards the midline, varus deformity. For example, genu valgum means knock-kneed and genu varum, bow-legged.


Look for abnormal bone alignment. Subluxation is said to be present when displaced parts of the joint surfaces remain partly in contact. Dislocation is used to describe displacement where there is loss of contact between the joint surfaces.


Muscle wasting results from a combination of disuse of the joint, inflammation of the surrounding tissues and sometimes nerve entrapment. It tends to affect muscle groups adjacent to the diseased joint (e.g. quadriceps wasting with active arthritis of the knee) and is a sign of chronicity.



Feel


Palpate for skin warmth. This is done traditionally with the backs of the fingers where temperature appreciation is said to be better. A cool joint is unlikely to be involved in an acute inflammatory process. A swollen and warm joint may be affected by active synovitis (see below), infection (e.g. Staphylococcus) or crystal arthritis (e.g. gout).


Tenderness is a guide to the acuteness of the inflammation, but may be present over the muscles of patients with fibromyalgia. The patient must be told to let the examiner know if the examination is becoming uncomfortable. Tenderness can be graded as follows:






This may result from joint inflammation or from lesions outside the joints (periarticular tissues), including inflamed tendons, bursae, or attachments (entheses). Infected joints are extremely tender and patients will often not let the examiner move the joint at all. Palpation of a joint or area for tenderness must be performed gently, and the patient’s face rather than the joint itself should be watched for signs that the examination is uncomfortable.


Palpate the joint deliberately now, if possible, for evidence of synovitis, which is a soft and spongy (boggy) swelling. This must be distinguished from an effusion, which tends to affect large joints but can occur in any joint. Here the swelling is fluctuant and can be made to shift within the joint. Bony swelling feels hard and immobile, and suggests osteophyte formation or subchondral bone thickening.





Assessment of individual joints



The hands and wrists (Figures 9.5 to 9.9)



Examination anatomy


The articulations between the phalanges are synovial hinge joints. The eight bones of the wrist (carpal bones) form gliding joints which allow wrist movements—flexion/extension and abduction/adduction as they slide over each other.










Look


Start the examination at the wrists and forearms. Inspect the skin for erythema, atrophy, scars and rashes. Look for swelling and its distribution. Next look at the wrist for swelling, deformity, ulnar and hyloid prominence. Then look for muscle wasting of the intrinsic muscles of the hand. This results in the appearance of hollow ridges between the metacarpal bones. It is especially obvious on the dorsum of the hand.


Go on to the metacarpophalangeal joints. Again note any skin abnormalities, swelling or deformity. Look especially for ulnar deviation and volar (palmar) subluxation of the fingers. Ulnar deviation is deviation of the phalanges at the metacarpophalangeal joints towards the medial (ulnar) side of the hand. It is usually associated with anterior (Volar) subluxation of the fingers (Figure 9.10). These deformities are characteristic but not pathognomonic of rheumatoid arthritis (Table 9.9).



TABLE 9.9 Differential diagnosis of a deforming polyarthropathy













Rheumatoid arthritis
Seronegative spondyloarthropathy, particularly psoriatic arthritis, ankylosing spondylitis or Reiter’s disease
Chronic tophaceous gout (rarely symmetrical)
Primary generalised osteoarthritis
Erosive or inflammatory osteoarthritis

Next inspect the proximal interphalangeal and distal interphalangeal joints. Again note any skin changes and joint swelling. Look for the characteristic deformities of rheumatoid arthritis. These include swan neck and boutonnière deformity of the fingers and Z deformity of the thumb (Figure 9.10). They are due to joint destruction and tendon dysfunction. The swan neck deformity is hyperextension at the proximal interphalangeal joint and fixed flexion deformity at the distal interphalangeal joint. It is due to subluxation at the proximal interphalangeal joint and tendon shortening at the distal interphalangeal joint. The boutonnière (buttonhole) deformity consists of fixed flexion of the proximal interphalangeal joint and extension of the distal interphalangeal joints. This is due to protrusion of the proximal interphalangeal joint through its ruptured extensor tendon. The Z deformity of the thumb consists of hyperextension of the interphalangeal joint and fixed flexion and subluxation of the metacarpophalangeal joint.


Now look for the characteristic changes of osteoarthritis (Figure 9.11). Here the distal interphalangeal and first carpometacarpal joints are usually involved. Heberden’s nodese are a common deformity caused by marginal osteophytes that lie at the base of the distal phalanx. Less commonly, the proximal interphalangeal joints may be involved and osteophytes here are called Bouchard’sf nodes.



Look also to see if the phalanges appear sausage-shaped. This is characteristic of psoriatic arthropathy, but can also occur in patients with Reiter’s disease. It is due to interphalangeal arthritis and flexor tendon sheath oedema. Finger shortening due to severe destructive arthritis also occurs in psoriatic disease and is called arthritis mutilans. The hand may take up a main en lorgnette (‘hand holding long-handled opera glasses’) appearance due to a combination of shortening and telescoping of the digits.


Now examine the nails. Characteristic psoriatic nail changes may be visible: these include pitting (small depressions in the nail), onycholysis (Figure 9.12) and, less commonly, hyperkeratosis (thickening of the nail), ridging and discoloration. The presence of vasculitic changes around the nailfolds implies active disease. These consist of black to brown 1–2 mm lesions due to skin infarction and occur typically in rheumatoid arthritis (Figure 9.13). Splinter haemorrhages may be present in patients with systemic lupus erythematosus (and infective endocarditis) and are due to vasculitis. Unlike nailfold infarcts they are located under the nails in the nail beds. Periungual telangiectasiae occur in systemic lupus erythematosus, scleroderma or dermatomyositis.




The hands should now be turned over and the palmar surfaces revealed. Look at the palms for scars (from tendon repairs or transfers), palmar erythema, and muscle wasting of the thenar or hypothenar eminences (due to disuse, vasculitis or peripheral nerve entrapment). Telangiectasia here would support the diagnosis of scleroderma.



Feel and move


Turn the hands back again to the palm-down position. Palpate the wrists with both thumbs placed on the dorsal surface by the wrists, supported underneath by the index fingers (Figure 9.14). Feel gently for synovitis (boggy swelling) and effusions. The wrist should be gently dorsiflexed (normally possible to 75 degrees) and palmar flexed (also possible to 75 degrees) with the examiner’s thumbs. Then radial and ulnar deviation (20 degrees) is tested (Figure 9.15). Note any tenderness or limitation of movement or joint crepitus. Palpate the ulnar styloid for tenderness, which can occur in rheumatoid arthritis.




Test for tenderness at the tip of the radial styloid. This suggests de Quervain’sg tenosynovitis.


Feel for tenderness in the anatomical snuff box if scaphoid injury is suspected (Figure 9.15). Test for tenderness distal to the head of the ulna for extensor carpi ulnaris tendinitis.


Go on now to the metacarpophalangeal joints, which are palpated in a similar way with the two thumbs. Again passive movement is tested. Volar subluxation can be demonstrated by flexing the metacarpophalangeal joint with the proximal phalanx held between the thumb and forefinger. The metacarpophalangeal joint is then rocked backwards and forwards (Figure 9.16). Very little movement occurs with this manoeuvre at a normal joint. Considerable movement may be present when ligamentous laxity or subluxation is present.



Palpate the proximal and distal interphalangeal joints for tenderness, swelling and osteophytes.


Next test for palmar tendon crepitus. The palmar aspects of the examiner’s fingers are placed against the palm of the patient’s hand while he or she flexes and extends the metacarpophalangeal joints. Inflamed palmar tendons can be felt creaking in their thickened sheaths and nodules can be palpated. This indicates tenosynovitis.


A trigger finger may also be detected by this manoeuvre. Here the thickening of a section of digital flexor tendon is such that it tends to jam when passing through a narrowed part of its tendon sheath. Rheumatoid arthritis is an important cause. Typically, flexion of the finger occurs freely up to a certain point where it sticks and cannot be extended (as flexors are more powerful than extensors). The application of greater force overcomes the resistance with a snap.


If the carpal tunnel syndrome is suspected, ask the patient to flex both wrists for 30 seconds—paraesthesiae will often be precipitated in the affected hand if the syndrome is present (Phalen’sh wrist flexion test). The paraesthesiae (pins and needles) are in the distribution of the median nerve (page 363), when thickening of the flexor retinaculum has entrapped the nerve in the carpal tunnel (Table 9.10). This test is more reliable than Tinel’s sign,i in which tapping over the flexor retinaculum (which lies at the proximal part of the palm) may cause similar paraesthesiae.4


TABLE 9.10 Causes of carpal tunnel syndrome


















Now test active movements. First assess wrist flexion and extension as shown in Figure 9.17. Compare the two sides. Now go on to thumb movements (Figure 9.18). The patient holds the hand flat, palm upwards, and the examiner’s hand holds the patient’s fingers. Test extension by asking the patient to stretch the thumb outwards, abduction by asking for the thumb to be pointed straight upwards, adduction by asking him or her to squeeze the examiner’s finger, and opposition by getting the patient to touch the little finger with the thumb. Look for limitation of these movements and discomfort caused by them. Next test metacarpophalangeal and interphalangeal movements. As a screening test, ask the patient to make a fist then to straighten out the fingers (Figure 9.19). Then test the fingers individually. If active flexion of one or more fingers is reduced, test the superficial and profundus flexor tendons (Figure 9.20). Hold the proximal finger joint extended and instruct the patient to bend it; the distal fingertip will flex if the flexor profundus is intact. Then hold the other fingers extended (to inactivate the profundus) and check finger flexion (inability indicates the superficialis is unable to work). The most common tendon ruptures are of the extensors of the fourth and fifth fingers.







Function


It is important to test the function of the hand. Grip strength is tested by getting the patient to squeeze two of the examiner’s fingers. Even an angry patient will rarely cause pain if given only two fingers. Serial measurements of grip strength can be made by asking the patient to squeeze a partly inflated sphygmomanometer cuff and noting the pressure reached. Key grip (Figure 9.21) is the grip with which a key is held between the pulps of the thumb and forefinger. Ask the patient to hold this grip tightly and try to open up his or her fingers. Opposition strength (Figure 9.22) is where the patient opposes the thumb and individual fingers. The difficulty with which these can be forced apart is assessed. Finally, a practical test, such as asking the patient to undo a button or write with a pen, should be performed.




Tests of hand function should be completed by formally assessing for neurological changes (page 362).


Examination of the hands is not complete without feeling for the subcutaneous nodules of rheumatoid arthritis near the elbows (Figure 9.23). These are 0.5–3 cm firm, shotty, non-tender lumps which occur typically over the olecranon. They may be attached to bone. They are found in rheumatoid-factor-positive rheumatoid arthritis. Rheumatoid nodules are areas of fibrinoid necrosis with a characteristic histological appearance and are probably initiated by a small vessel vasculitis. They are localised by trauma but can occur elsewhere, especially attached to tendons, over pressure areas in the hands or feet, in the lung, pleura, myocardium or vocal cords. The combination of arthritis and nodules suggests the diagnostic possibilities listed in Table 9.11.



TABLE 9.11 Causes of arthritis plus nodules*











Rheumatoid arthritis
Systemic lupus erythematosus (rare)
Rheumatic fever (Jaccoud’s arthritis) (very rare)
Granulomas—e.g. sarcoidosis (very rare)

* Gouty tophi and xanthomata from hyperlipidaemia may cause confusion.


François Jaccoud (1830–1913), professor of medicine, Geneva.



The elbows





Examination


Watch as the patient undresses, for difficulty disentangling the arms from clothing. The upper arms should be exposed completely. Note any deformity or difference in the normal 5–10 degree valgus position (carrying angle) as the patient stands with the palms facing forward.


Look for a joint effusion, which appears as a swelling on either side of the olecranon. Discrete swellings over the olecranon or over the proximal subcutaneous border of the ulna may be due to rheumatoid nodules, gouty tophi, an enlarged olecranon bursa or, rarely, to other types of nodules (Table 9.11).


Feel for tenderness, particularly over the lateral and medial epicondyles which may indicate tennis or golfer’s elbow, respectively. Palpate any discrete swellings. Rheumatoid nodules are quite hard, may be tender and are attached to underlying structures. Gouty tophi have a firm feeling and often appear yellow under the skin, but are sometimes difficult to distinguish from rheumatoid nodules. A fluid collection in the olecranon bursa is softly fluctuant and may be tender if inflammation is present. These collections are associated with rheumatoid arthritis and gout, but often occur independently of these diseases.


Small amounts of fluid or synovitis of the elbow joint may be detected by the examiner, facing the patient, placing the thumb of the opposite hand along the edge of the ulnar shaft just distal to the olecranon where the synovium is closest to the surface. Full extension of the elbow joint will cause a palpable bulge in this area if fluid is present.


Move the elbow joints passively. The elbow is a hinge joint. The zero position is when the arm is fully extended (0 degrees). Normal flexion is possible to 150 degrees. Limitation of extension is an early sign of synovitis.


If lateral epicondylitis is suspected, ask the patient to extend the wrist actively against resistance (see Figure 9.70, page 291). Test the range of active movements by standing in front of the patient and demonstrating. If there is any deformity or complaint of numbness, a neurological examination of the hand and arm are indicated for ulnar nerve entrapment.


Oct 26, 2017 | Posted by in GENERAL SURGERY | Comments Off on The rheumatological system

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