Case 19 Rheumatoid Arthritis


Case 19
Rheumatoid Arthritis
Clinical Examination

Introduction ownself
Exposure – Upto Umbilicus 
Hand scrubbing
Look- Standing Patient

Comment on Cervical Collar
Attitude of the limb
Alignment       -           Front    Head at Centre
 Both shoulders are leveled,
                                                Chest is symmetric on both the sides
                                    No wasting of muscles on chest , shoulder ,arm , forearm                                                     , thenar and hypothenar muscles with normal overlying skin

                                    Side       Normal cervical lordosis
                                                  Maintained deltoid contour , elbows extended ,
                                    Back               
  Spinal curvature is maintained with no kyphoscoliosis
  Normal overlying skin on back with no dimpling , tuft of hair
      and swelling
 No wasting of muscles on supr and intraspinatus fossa ,shoulder               and dorsal surface of arm , forearm and hands

Gait                                         Normal / Stooped wide based gait /frequent fall or early shuffling
Ask Patient to Sit
Neck ROM –                          Decreased ROM
Lumbar                                    Decreased ROM
Spurling sign + -                      Hyperextension + Lateral rotation towards affected side + gentle           compression – if illicits Pain – s/o Radiculopathy
Shoulder Abduction sign        + , Relief of pain with hands putting on head with shoulder abducted.
Hoffman’s Reflex                   Reflex – thumb and other fingers extend with sudden long finger DIP joint extension
Scapulohumeral Reflex           Taping spine of scapula illicits a brisk scapular elevation and abduction of humerus .
Reverse Asymmetric Jerk       Biceps / Supinator
Inverted Radial Reflex           During testing Brachioradialis reflex , the response is reciprocal spastic contracture of fingers.
Lhermitte’s Sign                     Neck – Flexion leads to burning sensation involving upper and lower extremities and trunk.
Finger Escape Sign                 In making a grip , 2 ulnar digits drift out.
                                                In grip and release test , patient unable to form a fist and release all digits within 10 seconds period
Neurovascular Examination
UE – C 5 – T 1
LE – l2 – S 5
Spasticity / Clonus
Sensation – including joint position which is maintained
Power

Reflexes – Knee and Ankle – Brisk bilaterally
                  Plantar reflex upgoing
Sitting   -                                 Upper Extremity Examination /Lower Extremity
                
Look –                                     Skin
                                                Muscle Wasting

Feel –                                      Temperature
                        Tenderness
                        Lymph Nodes


Move                                       Shoulder / Elbow / Wrist and Hands
Hip / Knee / Ankle / Toes                   



In case of Myelopathy spasticity , clonus , brisk reflexes , plantar upgoing.
Cervical Radiculopathy has LMN type presentation



C- Spine
1)Chamberlain Line – Posterior edge of hard palate to posterior border of foramen magnum
Odontoid is 5 mm above this leads to Basilar Imression leading to Brainstem and Spinal Cord compression
2)Mc Gregor Line – Posterior edge of hard palate to most caudal portion of occipital curve
 4.5 mm above this suggest Basilar Impression
3) Mc Rae line –Determines AP dimension of foramen magnum and is drawn from anterior lip to posterior lip. In normal patients odontoid tip falls below this line.
4)Ranawat Lines – Perpendicular distance between centre  of sclerotic ring of C2 and line drawn along axis of C 1 .
            Normal 15 mm.

Ranwat Classification
I – Subjective paresthesia
II – Subjective findings UMN
III-Subjective findings UMN

Other Investigations
MRI

Management
Surgery – Spinal Surgery Consultation
                        Pain , instability , Neurological Symptoms



Comments

Post a Comment

Popular posts from this blog

Outline of Treatment of Spinal Tuberculosis

Image
 Tuberculosis     In general , Rest and Nutrition                                 Chemotherapy                                Surgery if needed .                                    Dorsal Spine - Approach to surgery     A bit ambiguous      Many prefer to do Anterior Transpleural. Some choose Anterolateral/posterolateral extrapleural                and posterolateral approaches      Posterolateral Approach(Martin 1970)      Dura exposed by Hemilaminectomy first and then operation extended laterally to remove posterior         ends of 2 to 4 ribs, corresponding transverse process and pedicles.      He thinks  Anterolateral approach a very risky one.     Approach to Atlanto-occipital and Atlanto-axial joint         Numerous structures on the way anteriorly     Supine position, Neck on 5-10 degrees hyperextension ,Trachesostomy done     Transoral Anterior Approach           Uvula, Soft palate bissected , Hypopharynx packed, 5 cm long incision given, Flaps                                 
Read more

COXA VARA

Image
Coxa Vara Painless limp, LLD gradually worsening ,  Unilateral or bilateral in 30-50 % cases Prominent trochanters Pelvic Tilt- LLD  Trendelenburg test or delaye trendelenburg test + ve B/L waddling  High Greater trochnater - supratrochanteric shortening,  Decreased abduction, (decrease in articular trochanteric distance ) and internal rotation (due to decreased anteversion) may have out toeing r/o cervical instability causing limping  Types of Coxa Vara  https://quizlet.com/au/304405013/coxa-vara-flash-cards/ Mangement      Depends on Hilgenreiner Angle (HEA ) https://www.orthobullets.com/pediatrics/4041/developmental-coxa-vara  > 60 degrees - wait and watch    45-60 degrees - wait and watch  Goals of surgery      Neck shaft angle  (more or equal ) to 140.              degrees     Correct version      Ossification and healing of inferomedial.               fragment      Restore ATD (Articulo-trochanteric            distance    AND abductor mechanism                 (length -tension
Read more

Paediatric Supracondylar Humerus Fracture

Image
Supracondylar Fracture  Patient Presentation         Age 6-10 years         MOI - Fall on outstretched hand with elbow on extension, breaks.   Olecranon serves as the fulcrum      and the stress concentrates in distal humerus. Anteriorly the perisoteum hinges.     Pain , swelling, deformity, bruising      Deformity (usually S shaped ) , skin puckering      Compartment syndrome         Blood vessels spasm/ contusion/ tear/ thrombosis     If capillary refill present , hand arm Dunlop traction done.      No role of Angiography , further delays the treatment.      Nerve Injuries, proximal fragment spike hits nerve.             3a Posteromedial displacement - Radial Nerve involvement             3b Posterolateral displacement - Median Nerve involvement     Gartland and Wilkins Classification      Extension type fracture      1. Undisplaced Fracture      2. Displaced Fracture , posterior cortex is.                intact     3. Displaced fracture, posterior cortex breaks      Flexion type occ
Read more

Hind Foot amputation

Image
Boyd Amputation -Tibiocalcaneal arthodesis, heel pad preserved. ( https://www.semanticscholar.org/ ) ( Modifizierte Pirogoff-Amputation | SpringerLink ) Pirgoff Amputation  Amputation at ankle. part of calcanuem left in the stump , Calcaneum cut vertically.  Advantages  long lever arm , self suspension , good proprioception , end wt bearing.  Disadvantages  poor cosmesis , too long to use standard foot , no possibility of prosthetic foot fitting 
Read more

Timing and Outcome of Surgery in Hip Fractures

Hip Joint Ball and Socket joint. Hip fracture is any fracture involving Interochanteric region head, neck or acetabulum. 310,000 Hip fractures in the United State in 2003     1/3 rd - receive a hip replacement.     10.3 - 15.2 billion dollars / year Elderly – Vast Majority  Co-morbidities Femoral Neck Fracture Fracture Healing is delayed due to          - I ntracapusular neck- No Cambium layer          - Synovial fluid clears out haematoma and inhibits fracture union          - Haematoma causes pressure on head Mechanism of injury  • Directly on lateral hip • Twisting mechanism • Fatigue or insufficiency fracture, then fall • In younger - RTA /  fall from a height Risk Factors of Hip Fractures   • Osteoporosis and Falls   Lifetime risk -17.5 percent for women : 6 percent for men  • Average -   women 77 years old  :  men 72 years old • Low socioeconomic status • Cardiovascular diseas
Read more