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Rheumatological Examination
HISTORY TAKING AND EXAMINATION
Rheumatological Examination
Important points in the history • Constant, unremitting pain suggests the possibility of malignant disease • Pain that keeps the patient awake suggests malignant disease or severe arthritis • Root pain is often burning or tingling in nature • Pain and stiffness that improve with activity suggest an inflammatory disorder • Musculoskeletal disease may be drug-induced
Jane E Dacre Jennifer G Worrall
The locomotor system can be difficult to examine because it involves many different anatomical structures. A full examination is time-consuming and seldom necessary. Most rheumatologists perform a short screening examination followed by a more detailed assessment of the affected structures, with additional examination of other systems if indicated. Variations in examination technique reflect individual practice. This contribution outlines the GALS (gait, arms, legs, spine) screen, which is a quick, reliable screen of the locomotor system, and describes more detailed examination of the lumbar spine, hip, knee, shoulder, elbow, hand and wrist, which are the most common sites for symptoms of locomotor disease.
osteoarthritis of the neck in dentists, osteoarthritis of the feet in dancers). Specific occupational rheumatic diseases such as housemaid’s knee (prepatella bursitis) and weaver’s bottom (ischial bursitis) should also be considered. Ask patients about their job, what they do exactly and how they do it, and how often they take a break. Excessive wrist action (e.g. in a painter and decorator) may cause tenosynovitis. Leisure activities can also predispose individuals to joint pain (e.g. tennis elbow). Ask about violent physical exercise (e.g. contact sports) and excessive joint movement (e.g. gymnastics, yoga); these may cause long-term damage to joints. It is useful to ask about general exercise and the patient’s level of fitness. Individuals who are unfit may develop nonspecific aches and pains in their joints and muscles.
Anatomy and physiology of the locomotor system The locomotor system comprises bones, joints and muscles with associated ligaments, tendons and bursae. The principal types of joint are fibrous and synovial. Synovial joints permit a wide range of movement. Fibrous joints have a simpler structure than synovial joints and are less susceptible to disease and injury; the bones are connected by dense fibrous tissue and only a small range of movement is permitted. In a synovial joint (Figure 1), the bone ends are covered by hyaline cartilage and the whole structure is enclosed in a capsule. The capsule is lined with synovium – a specialized tissue responsible for lubricating the joint and nourishing the articular cartilage, which has no blood supply of its own. Synovium produces synovial fluid by a combination of ultra-filtration of plasma and active secretion of large molecules (e.g. hyaluronan). Normal synovial fluid is highly viscous because of entanglement of these molecules, whereas inflammatory synovial fluid has a low viscosity because the enzymes and free radicals associated with inflammation break them down. The two main causes of arthritis are degeneration and inflammation. In degenerative disease (osteoarthritis), the articular cartilage becomes dehydrated, thin and fibrillated. Abnormal mechanical stress is transmitted to the underlying bone, which
Treatment history Ask the patient about treatment with aspirin and non-steroidal anti-inflammatory drugs, to assess efficacy and side effects (particularly gastric irritation and gastrointestinal bleeding). Establish whether those with RA have taken any second-line therapy (e.g. sulfasalazine, methotrexate, sodium aurothio-malate, D-penicillamine, azathioprine, hydroxy-chloroquine) and whether they developed any side effects (e.g. rashes) that led to stopping of the drug. Remember that patients with inflammatory arthritic conditions may also be taking long-term corticosteroid therapy and may have associated side effects (e.g. diabetes, osteoporosis). Some connective tissue diseases are drug-induced; for example, patients taking long-term phenothiazines for psychiatric conditions may develop a lupus-like syndrome.
FURTHER READING Dacre J E, Kopelman P. Handbook of Clinical Skills. London: Manson, 2002. Doherty M, Dacre J, Dieppe P, Snaith M. The (GALS) Locomotor Screen. Ann Rheumatol 1992; 51: 1165–9.
Jane E Dacre MBBS BSc MD FRCP ILTM is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London.
Acknowledgement The authors thank Manson Publishing and the Photography and Illustrations Centre at the Archway Campus, Royal Free and University College London, UK.
THE FOUNDATION YEARS 2:2
Jennifer G Worrall MD FRCP is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
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HISTORY TAKING AND EXAMINATION
Structure of a synovial joint
Record of the GALS locomotor system screening examination in a normal patient
Muscle
Appearance
Bone
• • • •
Bursa
Synovium
Arms • Ask the patient to hold out the hands, palms down. Inspect the arms for obvious abnormalities (e.g. swelling, deformity, nodules). Inspect the hands for skin or nail changes that may be associated with arthritis (e.g. the scaly rash or onycholysis of psoriasis (Figure 3), the digital vasculitis of systemic lupus erythematosus, the colour changes of Raynaud’s disease). • Ask the patient to turn the hands over. This assesses the radioulnar joint, which is commonly affected in RA (Figure 4). Ensure that the elbows are tucked in to prevent the patient using his or her shoulders to reproduce this movement. Inspect the palms, looking for signs such as Dupuytren’s contracture and thenar wasting. • Ask the patient to make a tight fist with each hand (Figure 5) and check that the fingers flex fully into the palms. Power of grip can be assessed by offering the index and middle fingers of your hands and asking the patient to grip your fingers tightly. • Ask the patient to place the tip of the index finger onto the tip of the thumb. This assesses opposition of the thumb and fine movements, which are often limited in RA. • Squeeze across the hand from the second to the fifth metacarpophalangeal joints, to assess tenderness. • Ask the patient to put the hands behind the head, pressing the elbows back (Figure 6). This movement assesses abduction and external rotation at the shoulders and flexion at the elbows, and is of functional importance in combing the hair.
Hyaline cartilage Tendon Joint capsule Enthesis
Structures in bold may give rise to pain or tenderness
remodels, becoming sclerotic and forming osteophytes at the joint margins. Inflammatory disease (e.g. rheumatoid arthritis, RA) is characterized by primary inflammation of the synovium (synovitis), which damages the articular cartilage and bone, leading to bony erosion. Synovium also lines the tendon sheaths and bursae, which may be involved in the disease process. Tendons, ligaments and fascial structures are attached to the periosteum by a specialized structure called the enthesis. Ankylosing spondylitis and related inflammatory arthritis are associated with inflammation of the enthesis. Plantar fasciitis is an enthesitis.
GALS screen
Legs • With the patient lying supine on the couch, inspect for flexion deformity at the hip or knee, then passively flex the hip and knee with a hand placed over the knee. Assess knee flexion while feeling for crepitus and assessing hip flexion. • Passively internally rotate the hip with the knee and hip still
Preliminary assessment using the GALS screen identifies most locomotor system problems. These problems can then be characterized in more detail using a regional examination. A method for recording the results of the GALS screen is shown in Figure 2. With the patient undressed to his or her underwear, look from the front, back and sides for any asymmetry or deformity such as unequal leg length, flexion deformity at hip or knee, or abnormality of spinal curvature (e.g. kyphosis, scoliosis, loss of lumbar lordosis). Gait Ask the patient to walk and observe whether he or she swings the arms and moves the legs symmetrically. The fluidity of the normal gait may be lost when a patient experiences pain, because persisent muscle contraction splints the painful part. In an antalgic gait, the patient avoids bearing weight on the painful leg or foot and spends most of the gait cycle on the unaffected leg. If the gait is normal, the patient is unlikely to have any major locomotor problems in the legs or lumbar spine.
THE FOUNDATION YEARS 2:2
2
Cavity (joint space) containing synovial fluid
1
G – gait A – arms L – legs S – spine
Movement
3 Onycholysis in psoriatic arthritis.
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HISTORY TAKING AND EXAMINATION
4 Assessment of radio-ulnar function.
6 Assessment of abduction and external rotation of the shoulders.
5 Making a tight fist to assess hand power and function.
7 Flexion of the knee with internal rotation of the hip.
flexed (Figure 7). Internal rotation is the first movement to become restricted in hip disease. • Ask the patient to dorsiflex, extend, invert and evert the ankle to assess tibiotalar movement (affected by osteoarthritis) and subtalar movement (affected by RA). • Squeeze across the foot at the level of the metatarsophalangeal joints, looking for tenderness.
• Look for swelling and deformity. • Feel to assess whether swelling is soft (soft tissue or fluid) or hard (bony) and, if it is soft, whether it is warm or cool. • Move the joint to assess range of movement and instability. Do not worry if you cannot remember the range of movement of all the joints. If the problem is unilateral, you can compare the abnormal side with the normal side; if it is bilateral, compare it with your own joints.
Spine • With the patient standing, ask him or her to put the ear on the shoulder on the same side, keeping the shoulder still (Figure 8). This assesses lateral flexion of the cervical spine, which is the first movement to become restricted in degenerative or inflammatory disease. • Place two of your fingers over adjacent spinous processes in the lumbar region and ask the patient to bend over and touch the toes. Your fingers should move apart. This is an essential part of the assessment of the lumbar spine because patients with a rigid spine caused by ankylosing spondylitis may be able to touch their toes without moving the spine if they have supple hips.
Neck and back pain The lumbar spine should be examined with the patient standing, then supine and then prone. Standing: look at the curvature of the spine. Scoliosis may be caused by muscle spasm in acute sciatica or may be postural if the patient’s legs are of unequal length. Loss of normal lordosis is a sign of inflammatory spinal disease (e.g. ankylosing spondylitis). Palpate the erector spinae muscles to assess spasm. Ask the patient to lean to each side in turn and run his or her hand down the side of the leg to the knee; this assesses lateral flexion, which is often the first movement to become restricted in spinal disease. Then ask the patient to lean backwards to assess extension. Painful extension suggests facet joint disease (usually degenerative). It is helpful to place your hands lightly on the patient’s shoulders when assessing lateral flexion and extension;
Joint examination for common symptoms If abnormalities are found using the GALS screen, a more detailed examination (‘look, feel, move’) of the abnormal joints should be performed.
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HISTORY TAKING AND EXAMINATION
Sciatic foot stretch
b
a Lasague b Bragard c Popliteal pressure c
8 Assessment of lateral flexion of the neck.
Lift the leg and flex and extend the knee (a); in patients with sciatic root irritation, this induces pain. Lift the straight leg to induce pain and confirm root irritation by lowering the leg slightly then dorsiflexing the ankle (b) or pushing into the popliteal fossa (c).
this gives patients confidence that you will support them if they feel unsteady. Percuss the spine gently with the side of your closed fist. This may elicit local tenderness in patients with metastases or infection in the bone.
Femoral foot stretch
b
Supine: with the patient on the couch, assess movements at both hips (see below) before performing the sciatic stretch test – straightleg raising may be restricted by hip disease in addition to muscle spasm in sciatica. To assess straight-leg raising, lift the leg from underneath the ankle (not by grasping the leg from above, which can cause pain), keeping the knee extended. When the limit is reached, perform the sciatic stretch test by passively dorsiflexing the ankle (Figure 9). The test assesses irritation of the lower lumbar and upper sacral nerve roots (L5–S1). If the patient complains of sensory disturbance (pain, pins and needles or numbness) anywhere below the knee, the test is positive. Pain in the lumbar spine or at the back of the knee, usually caused by tight hamstrings, is not relevant to the test. Gaenslen’s test should be performed with the patient supine; this stresses the sacroiliac joints and provokes pain in the affected joint when sacroiliitis is present. To perform the test, passively flex the hip and knee on one side, bringing the knee onto the patient’s trunk, then externally rotate and abduct the hip. While holding the leg in this position, grasp the contralateral iliac crest and attempt to distract it laterally. This stresses the sacroiliac joint on that side and, if the joint is inflamed, the patient complains of pain in the low back, over that joint. A brief neurological examination of the legs should also be performed with the patient supine.
a Extend hip b Flex knee a
Femoral root irritation is determined by flexing the knee (a) and then the hip (b) to stretch the roots. 9
sensory disturbance over the front of the thigh, the test is positive. Hip pain Disease of the hip joint causes pain in the groin that may radiate down the anterior thigh to the knee. Pain over the lateral pelvis and thigh generally results from trochanteric bursitis, whereas pain in the buttock may be caused by ischial bursitis, sacroiliitis or lumbar spine disease. To assess the hip joints, ask the patient to lie supine on the couch. Look for flexion deformity at the hip. The hip joints are deep and cannot be palpated directly. Assess flexion at the hip with the knee flexed to relax the hamstrings, then assess internal and external rotation in flexion (Figure 7); internal rotation is often restricted early in hip disease. Place the hip in the neutral position, extend the knee, and abduct and adduct the hip in turn (take care in patients who have undergone hip replacement, because forced adduction may cause dislocation). Extension is assessed by hanging the leg over the side of the couch or with the patient in the prone position.
Prone: ask the patient to turn over, remove the pillow from the head of the couch and place it under the pelvis and abdomen. This slightly flexes the lumbar spine and is a comfortable position for the patient. Palpate down the spinous processes in turn and along the erector spinae muscles to assess tenderness, then perform the femoral stretch test (Figure 9) to assess irritation of the upper lumbar nerve roots (L2 and L3), which contribute to the femoral nerve. Passively flex the knee and, holding the foot, gently extend the hip. If this provokes spasm of the quadriceps and the patient complains of
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a
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HISTORY TAKING AND EXAMINATION
Knee pain Ensure that the patient is sitting propped up on the couch with the knees extended and the legs relaxed. Look for flexion deformity and for valgus and varus deformities. Look at the quadriceps muscles, which may be wasted in significant knee disease. Look for swelling. Normal knees have a hollow on the side of the patella; disappearance of this in patients with a large effusion causes obvious suprapatellar swelling (Figure 10). The infrapatellar fat pads may be prominent but are normal. Depress the patella with your fingertips; when the pressure is released, it bounces up (the patella tap) when a large effusion is present. A small effusion may be detected by the ‘bulge’ test. Empty the hollow next to the medial aspect of the patella by stroking it firmly, then push with the flat of your hand against the lateral aspect of the knee. If the medial hollow is filled by a bulge, an effusion is present (the normal knee contains only 1–2 ml of fluid, insufficient to cause a bulge). Palpate the popliteal fossa for swelling, which is most often caused by a Baker’s cyst. Effusions and Baker’s cysts are most commonly found in inflammatory disease, but may also occur in osteoarthritis of the knee. Flex and extend the knee to its fullest extent in both directions, with your hand placed on the knee to feel for crepitus. Lift the foot off the couch to look for hyperextension beyond 10°; this is a feature of hypermobility syndrome and is commonly associated with mechanical knee pain. Assess stability by attempting to stretch the knee medially and laterally while holding it in a few degrees of flexion. If there is abnormal movement, the collateral ligaments are lax. Examine the anterior cruciate ligament using the Lachman test. Pull the tibia forwards on the femur with the knee flexed at 20–30°. Anterior movement suggests anterior cruciate instability. The anterior and posterior cruciate ligaments can also be tested by flexing the knee and stabilizing the foot on the bed. Hold the knee circumferentially just below the joint, with the thumbs anteriorly. Pull forwards to test the integrity of the anterior cruciate ligament, then push to test the posterior cruciate ligament. Instability is revealed as abnormal movement of the tibia in an anterior or a posterior direction.
11 Dropped fingers in rheumatoid arthritis.
vicular joint disease, which is confirmed by point tenderness over the joint and pain on forced extension of the shoulder. With the patient sitting and facing you, observe the shoulders for asymmetry and swelling. Effusions point anteriorly. Palpate the capsule over the anterior humeral head and the supraspinatus tendon over the lateral upper humerus for tenderness. Assess flexion, extension, abduction, adduction and internal and external rotation actively and passively. In glenohumeral joint disease such as adhesive capsulitis and RA (degenerative disease of this joint is not common), passive and active movements are equally restricted. In contrast, disease of the rotator cuff (e.g. calcific tendinitis, degenerative rupture) causes restricted active movements, but passive movements remain full. Painful arc syndrome is a feature of rotator cuff disease. It is detected by asking the patient to raise the arms above the head, close to the ears, with the palms turned outwards (i.e. with the shoulders internally rotated), then asking him or her to slowly lower the arms sideways. Increased pain, caused by compression of the inflamed tendon between the acromion and the rotating humeral head, occurs at some point in the arc of movement. Elbow pain The elbow is seldom affected by degenerative disease but is often involved in inflammatory arthritis, particularly rheuma-toid. Carefully inspect the extensor aspect of both elbows; this is a common site for psoriasis, gouty tophi and rheumatoid nodules, and an inflamed olecranon bursa may be found. Elbow effusions may be detected by loss of the gutters normally present between the olecranon and the medial and lateral epicondyles respectively. Ask the patient to hold the arms out sideways with the elbows fully extended and look for flexion deformities, then ask him or her to bend the elbows fully. The radio-ulnar joint has been assessed in the GALS screen, but if pronation or supination is painful or restricted, ask the patient to repeat the movement while you palpate the radial head on the lateral side of the elbow; you may feel crepitus.
Shoulder pain Shoulder pain has many causes. Pain from the glenohumeral joint (the shoulder joint proper) radiates to the front and side of the upper arm. Pain over the top of the shoulder suggests acromiocla-
Pain in the hand and wrist The hand is examined in detail in the GALS screen (see above), but the following tests should also be performed. When examining the hands, stand in front of the patient and examine both hands simultaneously, comparing the two sides. When you ask patients to hold out their hands, ensure they spread their fingers and do not rest their hands on their knees; you will otherwise miss minor degrees of flexion deformity of the fingers
10 Suprapatellar swelling.
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PATIENT SAFETY
and the dropped fingers characteristic of extensor tendon rupture (Figure 11). Pain in the fingers may be a result of osteoarthritis; look for bony swellings on the distal interphalangeal joints (Heberden’s nodes) and the proximal interphalangeal joints (Bouchard’s nodes). Pronounced soft tissue swelling of these joints indicates inflammatory arthritis. Severe inflammatory arthritis (e.g. rheumatoid, psoriatic) with marked bone loss may lead to ‘telescoping’ of the fingers, with redundancy of the soft tissues, and to flail joints, which have lost all integrity. A combination of fixed joints (caused by bony ankylosis) and flail joints is characteristic of psoriatic arthritis. Also assess hand function. Ask the patient to write his or her name, to fasten and unfasten buttons, and to hold a cup and bring it to the lips.
Prophylactic antibiotics in surgery F G Hampson E J Ridgway
This contribution discusses the theory of antibiotic prophylaxis (specific antibiotic prophylaxis regimens in surgery are available in REFERENCES).1–4 Background Prophylactic antibiotics were introduced in the 1960s and have become an established part of surgical care. In the UK, it is estimated that 1 in 10 patients admitted to hospital develops a healthcare-associated infection, costing the NHS an estimated £1 billion per annum. Included in these data are about 4% of surgical patients who develop a surgical-site infection, adding an average of 6.5 days to their hospital stay.
FURTHER READING Dacre J E, Kopelman P. A Handbook of Clinical Skills. London: Manson, 2002. (A guide to history-taking and examination of all systems.)
Use of prophylactic antibiotics Prophylactic antibiotics are given to prevent (not treat) surgical-site infections. They act in tandem with the host immune response and at best reduce, but cannot eliminate, the risk of sepsis. The main factor in deciding to use prophylactic antibiotics is the risk that a surgical-site infection will occur. This depends on the likelihood of contamination, the types of contaminating bacteria and a number of host factors. Surgery can be categorized into clean, clean-contaminated, contaminated and dirty, based on the expected load of contaminating bacteria. Sites contaminated with large numbers of virulent bacteria (e.g. abscess) are more likely to progress to a surgical-site infection. Contaminated and dirty categories require therapeutic antibiotics; prophylaxis is given for clean-contaminated and some clean surgery. In clean-contaminated surgery, the overall benefit outweighs the risks associated with prophylaxis. However, in clean surgery, the situation is not as clear-cut; the overall risk of a surgical-site infection without prophylaxis is about 1.4% and the risk reduction achieved by use of prophylaxis is relatively low. Consequently, the benefits of prophylactic antibiotics are generally considered too small to warrant administration and are outweighed by the risk of adverse effects. If the consequences of a surgical-site infection could be substantial (e.g. loss of vision due to postoperative endophthalmitis in cataract surgery) and even a small reduction in surgical-site infections is of overall benefit, prophylaxis for clean procedures is warranted.
Acknowledgement The authors thank Manson Publishing, London, UK for photographs of the GALS screen, and the Photography and Illustrations Centre at the Archway Campus, Royal Free and University College London, UK.
Practice points • A full examination is time-consuming and seldom necessary • Most rheumatologists perform a short screening examination (e.g. GALS) • If an abnormality is detected during the screen, a regional examination must be performed • Follow the ‘look, feel, move’ protocol
THE FOUNDATION YEARS 2:2
F G Hampson MB ChB MRCP DTM&H is a Specialist Registrar in Microbiology at Sheffield Teaching Hospitals Trust, Sheffield, UK. E J Ridgway MB BS BSc MD FRCPath is a Consultant Microbiologist at Sheffield Teaching Hospitals Trust, Sheffield, UK.
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Rheumatological Examination
Important points in the history • Constant, unremitting pain suggests the possibility of malignant disease • Pain that keeps the patient awake suggests malignant disease or severe arthritis • Root pain is often burning or tingling in nature • Pain and stiffness that improve with activity suggest an inflammatory disorder • Musculoskeletal disease may be drug-induced
Jane E Dacre Jennifer G Worrall
The locomotor system can be difficult to examine because it involves many different anatomical structures. A full examination is time-consuming and seldom necessary. Most rheumatologists perform a short screening examination followed by a more detailed assessment of the affected structures, with additional examination of other systems if indicated. Variations in examination technique reflect individual practice. This contribution outlines the GALS (gait, arms, legs, spine) screen, which is a quick, reliable screen of the locomotor system, and describes more detailed examination of the lumbar spine, hip, knee, shoulder, elbow, hand and wrist, which are the most common sites for symptoms of locomotor disease.
osteoarthritis of the neck in dentists, osteoarthritis of the feet in dancers). Specific occupational rheumatic diseases such as housemaid’s knee (prepatella bursitis) and weaver’s bottom (ischial bursitis) should also be considered. Ask patients about their job, what they do exactly and how they do it, and how often they take a break. Excessive wrist action (e.g. in a painter and decorator) may cause tenosynovitis. Leisure activities can also predispose individuals to joint pain (e.g. tennis elbow). Ask about violent physical exercise (e.g. contact sports) and excessive joint movement (e.g. gymnastics, yoga); these may cause long-term damage to joints. It is useful to ask about general exercise and the patient’s level of fitness. Individuals who are unfit may develop nonspecific aches and pains in their joints and muscles.
Anatomy and physiology of the locomotor system The locomotor system comprises bones, joints and muscles with associated ligaments, tendons and bursae. The principal types of joint are fibrous and synovial. Synovial joints permit a wide range of movement. Fibrous joints have a simpler structure than synovial joints and are less susceptible to disease and injury; the bones are connected by dense fibrous tissue and only a small range of movement is permitted. In a synovial joint (Figure 1), the bone ends are covered by hyaline cartilage and the whole structure is enclosed in a capsule. The capsule is lined with synovium – a specialized tissue responsible for lubricating the joint and nourishing the articular cartilage, which has no blood supply of its own. Synovium produces synovial fluid by a combination of ultra-filtration of plasma and active secretion of large molecules (e.g. hyaluronan). Normal synovial fluid is highly viscous because of entanglement of these molecules, whereas inflammatory synovial fluid has a low viscosity because the enzymes and free radicals associated with inflammation break them down. The two main causes of arthritis are degeneration and inflammation. In degenerative disease (osteoarthritis), the articular cartilage becomes dehydrated, thin and fibrillated. Abnormal mechanical stress is transmitted to the underlying bone, which
Treatment history Ask the patient about treatment with aspirin and non-steroidal anti-inflammatory drugs, to assess efficacy and side effects (particularly gastric irritation and gastrointestinal bleeding). Establish whether those with RA have taken any second-line therapy (e.g. sulfasalazine, methotrexate, sodium aurothio-malate, D-penicillamine, azathioprine, hydroxy-chloroquine) and whether they developed any side effects (e.g. rashes) that led to stopping of the drug. Remember that patients with inflammatory arthritic conditions may also be taking long-term corticosteroid therapy and may have associated side effects (e.g. diabetes, osteoporosis). Some connective tissue diseases are drug-induced; for example, patients taking long-term phenothiazines for psychiatric conditions may develop a lupus-like syndrome.
FURTHER READING Dacre J E, Kopelman P. Handbook of Clinical Skills. London: Manson, 2002. Doherty M, Dacre J, Dieppe P, Snaith M. The (GALS) Locomotor Screen. Ann Rheumatol 1992; 51: 1165–9.
Jane E Dacre MBBS BSc MD FRCP ILTM is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London.
Acknowledgement The authors thank Manson Publishing and the Photography and Illustrations Centre at the Archway Campus, Royal Free and University College London, UK.
THE FOUNDATION YEARS 2:2
Jennifer G Worrall MD FRCP is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
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© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Structure of a synovial joint
Record of the GALS locomotor system screening examination in a normal patient
Muscle
Appearance
Bone
• • • •
Bursa
Synovium
Arms • Ask the patient to hold out the hands, palms down. Inspect the arms for obvious abnormalities (e.g. swelling, deformity, nodules). Inspect the hands for skin or nail changes that may be associated with arthritis (e.g. the scaly rash or onycholysis of psoriasis (Figure 3), the digital vasculitis of systemic lupus erythematosus, the colour changes of Raynaud’s disease). • Ask the patient to turn the hands over. This assesses the radioulnar joint, which is commonly affected in RA (Figure 4). Ensure that the elbows are tucked in to prevent the patient using his or her shoulders to reproduce this movement. Inspect the palms, looking for signs such as Dupuytren’s contracture and thenar wasting. • Ask the patient to make a tight fist with each hand (Figure 5) and check that the fingers flex fully into the palms. Power of grip can be assessed by offering the index and middle fingers of your hands and asking the patient to grip your fingers tightly. • Ask the patient to place the tip of the index finger onto the tip of the thumb. This assesses opposition of the thumb and fine movements, which are often limited in RA. • Squeeze across the hand from the second to the fifth metacarpophalangeal joints, to assess tenderness. • Ask the patient to put the hands behind the head, pressing the elbows back (Figure 6). This movement assesses abduction and external rotation at the shoulders and flexion at the elbows, and is of functional importance in combing the hair.
Hyaline cartilage Tendon Joint capsule Enthesis
Structures in bold may give rise to pain or tenderness
remodels, becoming sclerotic and forming osteophytes at the joint margins. Inflammatory disease (e.g. rheumatoid arthritis, RA) is characterized by primary inflammation of the synovium (synovitis), which damages the articular cartilage and bone, leading to bony erosion. Synovium also lines the tendon sheaths and bursae, which may be involved in the disease process. Tendons, ligaments and fascial structures are attached to the periosteum by a specialized structure called the enthesis. Ankylosing spondylitis and related inflammatory arthritis are associated with inflammation of the enthesis. Plantar fasciitis is an enthesitis.
GALS screen
Legs • With the patient lying supine on the couch, inspect for flexion deformity at the hip or knee, then passively flex the hip and knee with a hand placed over the knee. Assess knee flexion while feeling for crepitus and assessing hip flexion. • Passively internally rotate the hip with the knee and hip still
Preliminary assessment using the GALS screen identifies most locomotor system problems. These problems can then be characterized in more detail using a regional examination. A method for recording the results of the GALS screen is shown in Figure 2. With the patient undressed to his or her underwear, look from the front, back and sides for any asymmetry or deformity such as unequal leg length, flexion deformity at hip or knee, or abnormality of spinal curvature (e.g. kyphosis, scoliosis, loss of lumbar lordosis). Gait Ask the patient to walk and observe whether he or she swings the arms and moves the legs symmetrically. The fluidity of the normal gait may be lost when a patient experiences pain, because persisent muscle contraction splints the painful part. In an antalgic gait, the patient avoids bearing weight on the painful leg or foot and spends most of the gait cycle on the unaffected leg. If the gait is normal, the patient is unlikely to have any major locomotor problems in the legs or lumbar spine.
THE FOUNDATION YEARS 2:2
2
Cavity (joint space) containing synovial fluid
1
G – gait A – arms L – legs S – spine
Movement
3 Onycholysis in psoriatic arthritis.
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© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
4 Assessment of radio-ulnar function.
6 Assessment of abduction and external rotation of the shoulders.
5 Making a tight fist to assess hand power and function.
7 Flexion of the knee with internal rotation of the hip.
flexed (Figure 7). Internal rotation is the first movement to become restricted in hip disease. • Ask the patient to dorsiflex, extend, invert and evert the ankle to assess tibiotalar movement (affected by osteoarthritis) and subtalar movement (affected by RA). • Squeeze across the foot at the level of the metatarsophalangeal joints, looking for tenderness.
• Look for swelling and deformity. • Feel to assess whether swelling is soft (soft tissue or fluid) or hard (bony) and, if it is soft, whether it is warm or cool. • Move the joint to assess range of movement and instability. Do not worry if you cannot remember the range of movement of all the joints. If the problem is unilateral, you can compare the abnormal side with the normal side; if it is bilateral, compare it with your own joints.
Spine • With the patient standing, ask him or her to put the ear on the shoulder on the same side, keeping the shoulder still (Figure 8). This assesses lateral flexion of the cervical spine, which is the first movement to become restricted in degenerative or inflammatory disease. • Place two of your fingers over adjacent spinous processes in the lumbar region and ask the patient to bend over and touch the toes. Your fingers should move apart. This is an essential part of the assessment of the lumbar spine because patients with a rigid spine caused by ankylosing spondylitis may be able to touch their toes without moving the spine if they have supple hips.
Neck and back pain The lumbar spine should be examined with the patient standing, then supine and then prone. Standing: look at the curvature of the spine. Scoliosis may be caused by muscle spasm in acute sciatica or may be postural if the patient’s legs are of unequal length. Loss of normal lordosis is a sign of inflammatory spinal disease (e.g. ankylosing spondylitis). Palpate the erector spinae muscles to assess spasm. Ask the patient to lean to each side in turn and run his or her hand down the side of the leg to the knee; this assesses lateral flexion, which is often the first movement to become restricted in spinal disease. Then ask the patient to lean backwards to assess extension. Painful extension suggests facet joint disease (usually degenerative). It is helpful to place your hands lightly on the patient’s shoulders when assessing lateral flexion and extension;
Joint examination for common symptoms If abnormalities are found using the GALS screen, a more detailed examination (‘look, feel, move’) of the abnormal joints should be performed.
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Sciatic foot stretch
b
a Lasague b Bragard c Popliteal pressure c
8 Assessment of lateral flexion of the neck.
Lift the leg and flex and extend the knee (a); in patients with sciatic root irritation, this induces pain. Lift the straight leg to induce pain and confirm root irritation by lowering the leg slightly then dorsiflexing the ankle (b) or pushing into the popliteal fossa (c).
this gives patients confidence that you will support them if they feel unsteady. Percuss the spine gently with the side of your closed fist. This may elicit local tenderness in patients with metastases or infection in the bone.
Femoral foot stretch
b
Supine: with the patient on the couch, assess movements at both hips (see below) before performing the sciatic stretch test – straightleg raising may be restricted by hip disease in addition to muscle spasm in sciatica. To assess straight-leg raising, lift the leg from underneath the ankle (not by grasping the leg from above, which can cause pain), keeping the knee extended. When the limit is reached, perform the sciatic stretch test by passively dorsiflexing the ankle (Figure 9). The test assesses irritation of the lower lumbar and upper sacral nerve roots (L5–S1). If the patient complains of sensory disturbance (pain, pins and needles or numbness) anywhere below the knee, the test is positive. Pain in the lumbar spine or at the back of the knee, usually caused by tight hamstrings, is not relevant to the test. Gaenslen’s test should be performed with the patient supine; this stresses the sacroiliac joints and provokes pain in the affected joint when sacroiliitis is present. To perform the test, passively flex the hip and knee on one side, bringing the knee onto the patient’s trunk, then externally rotate and abduct the hip. While holding the leg in this position, grasp the contralateral iliac crest and attempt to distract it laterally. This stresses the sacroiliac joint on that side and, if the joint is inflamed, the patient complains of pain in the low back, over that joint. A brief neurological examination of the legs should also be performed with the patient supine.
a Extend hip b Flex knee a
Femoral root irritation is determined by flexing the knee (a) and then the hip (b) to stretch the roots. 9
sensory disturbance over the front of the thigh, the test is positive. Hip pain Disease of the hip joint causes pain in the groin that may radiate down the anterior thigh to the knee. Pain over the lateral pelvis and thigh generally results from trochanteric bursitis, whereas pain in the buttock may be caused by ischial bursitis, sacroiliitis or lumbar spine disease. To assess the hip joints, ask the patient to lie supine on the couch. Look for flexion deformity at the hip. The hip joints are deep and cannot be palpated directly. Assess flexion at the hip with the knee flexed to relax the hamstrings, then assess internal and external rotation in flexion (Figure 7); internal rotation is often restricted early in hip disease. Place the hip in the neutral position, extend the knee, and abduct and adduct the hip in turn (take care in patients who have undergone hip replacement, because forced adduction may cause dislocation). Extension is assessed by hanging the leg over the side of the couch or with the patient in the prone position.
Prone: ask the patient to turn over, remove the pillow from the head of the couch and place it under the pelvis and abdomen. This slightly flexes the lumbar spine and is a comfortable position for the patient. Palpate down the spinous processes in turn and along the erector spinae muscles to assess tenderness, then perform the femoral stretch test (Figure 9) to assess irritation of the upper lumbar nerve roots (L2 and L3), which contribute to the femoral nerve. Passively flex the knee and, holding the foot, gently extend the hip. If this provokes spasm of the quadriceps and the patient complains of
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Knee pain Ensure that the patient is sitting propped up on the couch with the knees extended and the legs relaxed. Look for flexion deformity and for valgus and varus deformities. Look at the quadriceps muscles, which may be wasted in significant knee disease. Look for swelling. Normal knees have a hollow on the side of the patella; disappearance of this in patients with a large effusion causes obvious suprapatellar swelling (Figure 10). The infrapatellar fat pads may be prominent but are normal. Depress the patella with your fingertips; when the pressure is released, it bounces up (the patella tap) when a large effusion is present. A small effusion may be detected by the ‘bulge’ test. Empty the hollow next to the medial aspect of the patella by stroking it firmly, then push with the flat of your hand against the lateral aspect of the knee. If the medial hollow is filled by a bulge, an effusion is present (the normal knee contains only 1–2 ml of fluid, insufficient to cause a bulge). Palpate the popliteal fossa for swelling, which is most often caused by a Baker’s cyst. Effusions and Baker’s cysts are most commonly found in inflammatory disease, but may also occur in osteoarthritis of the knee. Flex and extend the knee to its fullest extent in both directions, with your hand placed on the knee to feel for crepitus. Lift the foot off the couch to look for hyperextension beyond 10°; this is a feature of hypermobility syndrome and is commonly associated with mechanical knee pain. Assess stability by attempting to stretch the knee medially and laterally while holding it in a few degrees of flexion. If there is abnormal movement, the collateral ligaments are lax. Examine the anterior cruciate ligament using the Lachman test. Pull the tibia forwards on the femur with the knee flexed at 20–30°. Anterior movement suggests anterior cruciate instability. The anterior and posterior cruciate ligaments can also be tested by flexing the knee and stabilizing the foot on the bed. Hold the knee circumferentially just below the joint, with the thumbs anteriorly. Pull forwards to test the integrity of the anterior cruciate ligament, then push to test the posterior cruciate ligament. Instability is revealed as abnormal movement of the tibia in an anterior or a posterior direction.
11 Dropped fingers in rheumatoid arthritis.
vicular joint disease, which is confirmed by point tenderness over the joint and pain on forced extension of the shoulder. With the patient sitting and facing you, observe the shoulders for asymmetry and swelling. Effusions point anteriorly. Palpate the capsule over the anterior humeral head and the supraspinatus tendon over the lateral upper humerus for tenderness. Assess flexion, extension, abduction, adduction and internal and external rotation actively and passively. In glenohumeral joint disease such as adhesive capsulitis and RA (degenerative disease of this joint is not common), passive and active movements are equally restricted. In contrast, disease of the rotator cuff (e.g. calcific tendinitis, degenerative rupture) causes restricted active movements, but passive movements remain full. Painful arc syndrome is a feature of rotator cuff disease. It is detected by asking the patient to raise the arms above the head, close to the ears, with the palms turned outwards (i.e. with the shoulders internally rotated), then asking him or her to slowly lower the arms sideways. Increased pain, caused by compression of the inflamed tendon between the acromion and the rotating humeral head, occurs at some point in the arc of movement. Elbow pain The elbow is seldom affected by degenerative disease but is often involved in inflammatory arthritis, particularly rheuma-toid. Carefully inspect the extensor aspect of both elbows; this is a common site for psoriasis, gouty tophi and rheumatoid nodules, and an inflamed olecranon bursa may be found. Elbow effusions may be detected by loss of the gutters normally present between the olecranon and the medial and lateral epicondyles respectively. Ask the patient to hold the arms out sideways with the elbows fully extended and look for flexion deformities, then ask him or her to bend the elbows fully. The radio-ulnar joint has been assessed in the GALS screen, but if pronation or supination is painful or restricted, ask the patient to repeat the movement while you palpate the radial head on the lateral side of the elbow; you may feel crepitus.
Shoulder pain Shoulder pain has many causes. Pain from the glenohumeral joint (the shoulder joint proper) radiates to the front and side of the upper arm. Pain over the top of the shoulder suggests acromiocla-
Pain in the hand and wrist The hand is examined in detail in the GALS screen (see above), but the following tests should also be performed. When examining the hands, stand in front of the patient and examine both hands simultaneously, comparing the two sides. When you ask patients to hold out their hands, ensure they spread their fingers and do not rest their hands on their knees; you will otherwise miss minor degrees of flexion deformity of the fingers
10 Suprapatellar swelling.
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and the dropped fingers characteristic of extensor tendon rupture (Figure 11). Pain in the fingers may be a result of osteoarthritis; look for bony swellings on the distal interphalangeal joints (Heberden’s nodes) and the proximal interphalangeal joints (Bouchard’s nodes). Pronounced soft tissue swelling of these joints indicates inflammatory arthritis. Severe inflammatory arthritis (e.g. rheumatoid, psoriatic) with marked bone loss may lead to ‘telescoping’ of the fingers, with redundancy of the soft tissues, and to flail joints, which have lost all integrity. A combination of fixed joints (caused by bony ankylosis) and flail joints is characteristic of psoriatic arthritis. Also assess hand function. Ask the patient to write his or her name, to fasten and unfasten buttons, and to hold a cup and bring it to the lips.
Prophylactic antibiotics in surgery F G Hampson E J Ridgway
This contribution discusses the theory of antibiotic prophylaxis (specific antibiotic prophylaxis regimens in surgery are available in REFERENCES).1–4 Background Prophylactic antibiotics were introduced in the 1960s and have become an established part of surgical care. In the UK, it is estimated that 1 in 10 patients admitted to hospital develops a healthcare-associated infection, costing the NHS an estimated £1 billion per annum. Included in these data are about 4% of surgical patients who develop a surgical-site infection, adding an average of 6.5 days to their hospital stay.
FURTHER READING Dacre J E, Kopelman P. A Handbook of Clinical Skills. London: Manson, 2002. (A guide to history-taking and examination of all systems.)
Use of prophylactic antibiotics Prophylactic antibiotics are given to prevent (not treat) surgical-site infections. They act in tandem with the host immune response and at best reduce, but cannot eliminate, the risk of sepsis. The main factor in deciding to use prophylactic antibiotics is the risk that a surgical-site infection will occur. This depends on the likelihood of contamination, the types of contaminating bacteria and a number of host factors. Surgery can be categorized into clean, clean-contaminated, contaminated and dirty, based on the expected load of contaminating bacteria. Sites contaminated with large numbers of virulent bacteria (e.g. abscess) are more likely to progress to a surgical-site infection. Contaminated and dirty categories require therapeutic antibiotics; prophylaxis is given for clean-contaminated and some clean surgery. In clean-contaminated surgery, the overall benefit outweighs the risks associated with prophylaxis. However, in clean surgery, the situation is not as clear-cut; the overall risk of a surgical-site infection without prophylaxis is about 1.4% and the risk reduction achieved by use of prophylaxis is relatively low. Consequently, the benefits of prophylactic antibiotics are generally considered too small to warrant administration and are outweighed by the risk of adverse effects. If the consequences of a surgical-site infection could be substantial (e.g. loss of vision due to postoperative endophthalmitis in cataract surgery) and even a small reduction in surgical-site infections is of overall benefit, prophylaxis for clean procedures is warranted.
Acknowledgement The authors thank Manson Publishing, London, UK for photographs of the GALS screen, and the Photography and Illustrations Centre at the Archway Campus, Royal Free and University College London, UK.
Practice points • A full examination is time-consuming and seldom necessary • Most rheumatologists perform a short screening examination (e.g. GALS) • If an abnormality is detected during the screen, a regional examination must be performed • Follow the ‘look, feel, move’ protocol
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F G Hampson MB ChB MRCP DTM&H is a Specialist Registrar in Microbiology at Sheffield Teaching Hospitals Trust, Sheffield, UK. E J Ridgway MB BS BSc MD FRCPath is a Consultant Microbiologist at Sheffield Teaching Hospitals Trust, Sheffield, UK.
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