Ortho II Mid Term Review
Made by Trina Mumallah
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Differential Diagnosis: A process of evaluating your “best guess” diagnosis.
1. Consider the likely possibilities
2. Rule in or out with Examination and relevant questions in history( chief
complaint)
3. Decide which special tests may be informative
4. “Clinically indicated” if the test result will affect your treatment plan.
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Acute Pain: active inflammatory process (48-72 hrs)
Subacute Pain: > 72 hrs
Chronic Pain: more than 3 months. Associated with stages of healing; after
resolution of inflammation response.
Pain patterns:
1. Dermal pain: skin pain- superficial, soft tissues, usually localized
2. Sclerotomic pain: Deep somatic tissues (Connective tissue; achy- not
easily traced)
3. Visceral pain: internal organs
4. Radicular pain: Nerve roots; shooting electrical, burning ( follows
dermatomal pattern)
5. Phantom pain: post-amputation; perceives pain in limb that is not
physically present
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Muscle Grading Scale:
Muscle Gradations
5-Normal
4- Good
3- Fair
2- Poor
1- Trace
Description
Complete ROM against gravity with full
resistance
Complete ROM against gravity with
some resistance
Complete ROM against gravity
Complete ROM with gravity eliminated
Evidence of slight contractility No joint
Motion
No evidence of contractility
0- Zero
** Pain will decrease the numerical value
*** grading: objective- evaluates patient’s strength
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C5/6 disc herniation: biceps, brachioradialis, wrist extensors
Space occupying lesion: LMN
Sensation:
1. Light touch: ventral spinothalamic tract (pinwheels-plastic)
2. Pain: Lateral spinothalamic tract
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DTR: stretch reflex
Reinforcement physical (Jenjurassic)- document what you did to get the reflex
Distraction: Cognitive (count backwards, conversation, etc.)
C5-T1
Level
C5
Muscles
Deltoid, biceps
C6
Brachioradialis
Wrist extensors
Lateral arm and index
finger and thumb
Triceps, digit extensors
Wrist flexion
C7
C8
Digital flexion, right
finger, medial arm
Adduction/abductioninterossei
T1
Descriptions
Sensory high and lateral
Place thumb on deltoid
tendon; don’t press. Strike
hammer on thumb
Palpate brachioradialis
tendon strike with
hammer
DTR: triceps-produce
extension. Strike hammer
just above elbow
Curl fingers in
Push fingers together
Epaulette: dress braid-uniform; area deltoid attachment, axillary nerve
Range of Motion:
 3 attempts per motion
 All 3 should be within 10%; average and round to nearest 5
 Digital inclinometer can use exact number.
 Quantity vs Quality: How much pain and where its located
 Active: produced by muscle contraction.
 Passive: produced by outside force
 Passive > Active in a healthy joint.
 Monitor for degree measurement
 Rotation: 40-45° (45 is functional minimum)
 Atlas/Axis joint: Where the most rotation in the body occurs.
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Inspection: observation of patient, posture, scars, bruises, discoloration, hairy
patches (spina bifida), swelling or enlargement, atrophy
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Palpation: Static and motion
1. Static: tone, tissue resistance/compliance, temp. boggy with edema or
fluid
2. Motion: joint ROM, end-feel, pain
Pain is not the only/best indication or where to adjust
Orthopedic Tests:
 Relevant to chief complaint and region
 Have expectation for outcome of test based on differential diagnosis.
 Perform tests to verify/ rule out possible scenarios.
Neurologic Evaluation: Sensory, motor, reflex (DTR- appropriate for all
musculoskeletal regional exams)
Special tests: Determine X-ray and lab tests follow differential diagnosis (x-ray and
other imaging)
Soft Tissue Injury/ Diagnosis
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Strain: muscle injury
Sprain: ligamentous injury
** Code for both is the same-800 code = trauma
Grading for soft tissue injury/ strain
Grade
Clinical Findings
1
 Mild injury involving < 10% of
muscle/ belly; no cross sectional
tearing
 Mild moderate local
pain/tenderness; minimal limp
 Slight decrease in strength, slight
edema, bruise is unusual
 Minimal or microscopic injury
 Excellent response to
conservative treatment; low risk
of reinjury
2
 Significant and moderate injury
 10-50% of muscle/belly
 Marked decrease in ROM
3
 Complete rupture of all on a
functional portion of tissue
 50-100% severe injury
 Decreased strength
 Bruising and edema
Carnes p. 387 Phases of Soft Tissue Healing
1. Phase I: Acute inflammation (hyperemia or active congestion)
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Usually 1-2 days; may last up to 5 days depending on the tissue affected
and severity.
Involves both cellular and humoral elements
Homeostatis: vasoconstriction, platelet aggregation, thromboplastin clot
Inflammation: vasodilation, phagocytosis
Cardinal signs (SHARP): swelling, heat, a loss of function, redness, pain
Edema may not reach peak until 5-7 days post injury
Clinical Objectives: relieve pain, initiate vasoconstriction, disperse
fluids, increase circulation, maintain normal muscle tone, normal
ROM, and reduce effects of ischemia.
Rest, Ice, Compression, elevation (extremities)
2. Phase II: Post Acute Repair/ Proliferation (susceptible to reinjury)
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May last from 48 hours to 6 weeks
Involves synthesis and deposition of collagen (granulation and
epithelialization)
Macrophages/phagocytes remove cell debris, erythrocytes, and fibrin
clot
Collagen is not fully oriented in direction of tensile strength and
quality of collagen is inferior to original
Clinical Objective: Prevent early adhesions; orient repair tissue
along line of tension; relieve pain, maintain normal muscle tone
and ROM, reduce edema, exercises, return to normal activities
ASAP
3. Phase III: Remodeling (fibrosis aka scarring)
 May last from 3 weeks- 12 months or more
 Collagen is remodeling to increase the functional capabilities of the tendon or
ligament to withstand the stresses imposed upon it (pain free ROM and
stretching to help establish strength)
 Tensile strength of connective tissue is greatest in direction of the forces
imposed on it.
 Scar tissue is only 80% as strong as the original tissue
 Clinical Objectives: proper alignment of repair collagen (type III),
increase elasticity of scar tissue, reduce fibrotic adhesions, relieve muscle
spasms, increase strength and ROM. {rehab is key, motion (lymph,
vascular tissue, nutrition)}
Factors that IMPROVE healing
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Young age
Adequate nutrition
Healthy aerobic fitness and activity
level
Vit. A, C, E, calcitonin, H2O
Joint mobilization and massage
Anabolic steroids
Ultrasound, MENS
Injectable growth factors
Surgical gap closure
Laughter, positive mood and good
sleep habits
Factors that SLOW healing
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Increased age
Malnutrition
Smoking
NSAIDS/corticosteroids
Diabetes
Anti-coagulants
Prolonged immobilization/ rigid
fixation
Complete tear
Excessive motion or stress/repeat
injury
Depression, poor sleep habits
Cervical Acceleration/Deceleration injury
Hyperextension/hyperflexion
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Hyperextension: Occurs in response to acceleration; posterior compressive force;
anterior traction force; may be repeated cyclically due to reflex muscle
contraction in response to stretching.
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Hyperflexion: Occurs in response to deceleration; posterior traction force may
result in ligament sprain; anterior compression force; flexor muscles contract in
response to hyperextension stretch; may be exacerbated by seat belt restraint and
catapult response to head rest.
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Associated Clinical Areas Examination: cranial nerves, head and neck, including
lymph, thyroid, and swallowing, TMJ; function of eyes, spine, chest, upper and
lower extremities
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Post MVA: memory of impact? Loss of consciousness? Was this examined at the
scene or after? (Request records) relate accident to injury. Damage to vehicle
(photos, police report) onset and progression of symptoms, look beyond head and
neck area.
IVF Encroachment:
 Pain with compression
 Relief with distraction
 Pain follows associated dermatome
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Valsalva (cough, sneeze, straining), Dejerine’s Triad may be proactive and
reproduce radiating pain in the dermatome
 Sensory, motor and reflex findings may be consistant with LMN lesion
 Example: bone spur; posteriolateral disc lesion
 Other things that narrow IVF ( tumors, foreign bodies)
 IVF larger = relief
 IVF smaller = pain
Compression Tests:
 If IVF encroachment, look for radiating pain in the dermatome.
 If facet syndrome look for local pain at facet level or radiating pain that doesn’t
follow dermatome pattern; rather the pain with be located in the scleratome and
may be harder for patient to pin-point (wandering pain)
Somite
Dermatome
(Skin)
Myotome
(Muscle)
Scleratome
Connective tissue
(Joint capsule)
Produces “achy pain”
Cervical Ortho tests:
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O’Donoghue’s Maneuver: Contractile pain vs pain on passive motion
Pain with passive ROM = ligamentous
Resisted motion: muscle
Spinal Percussion: TTT (if fracture is suspected do not perform this!)
Distraction Test: lift occiput superior. Don’t place hands flat over ears as it can
create a vacuum; damaging the tympanic membrane.
1. If pain is relieved = compression injury or IVF encroachment
2. If produces pain = Facet, muscle injury
Maximal Foraminal Compression Test: Rotation and extension. Similar to
Kemps test. Doctor doesn’t have to touch patient to do this test
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TOS
Foraminal Compression Test: (aka cervical compression test) compress and
rotate 45°
Jackson’s Cervical Compression: lateral bending; compression- ↓ IVF ↑ chief
complaint on same side.
Rust’s Sign: Patient grasps head with both hands. Pain indicates- fracture; very
unstable (due to car wreck, diving accident, etc.) Red Flag! Migraine patients may
also show a + Rust’s sign.
Swallowing Test: tests for anterior disc herniation.
Spurlings: Narrowing of IVF. Flat hand- tap fist on hand- IVF encroachment.
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General term for a condition resulting in compression of neurovascular
structures( brachial plexus, subclavian artery and vein) at the thoracic outlet,
causing symptoms in the upper extremities, neck, and chest
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TOS is often over diagnosed; when it is present the C8-T1 spinal levels are
most commonly involved.
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Neurological: 90-97% females > males
Venous: 3-10% males > females
Arterial 1% males = females
Orthostatic hypotension : ↓ systolic ↓ radial pulse (positional radial pulse)tingling and numbness
 Signs (doctor) objective , symptoms (patient) subjective
 1st site of compression: between anterior and middle scalene
Whiplash
1st rib
Subluxation-cervical
 Post stenotic dilation: subclavian art., scalenes
 Enlarged vessel- weakens the wall. Called Bruit {Brewy}
 If gets large enough- aneurysm
Interscalene compression: use scalenes to breathe ↑ tension. Lung changes
 Look for positional aggrevation of chief complaint
 Symptoms are consistent with location site of compression
3 major categories
1. Neurologic (most common type):
 Pain; usually on the medial aspect of the arm,
forearm, and the ring and small digits
 Paresthesias- at night wakes patient up with
numbness and tingling
 Loss of dexterity, cold intolerance
 Raynaud’s phenomenon
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Due to MVA, repetitive stress at work
2. Venous:
 Pain (usually younger males-vigorous activity)
 Swelling of the arm, cyanosis
 Paresthesias in the fingers and hands
3. Arterial:
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Pain, pallor, coldness, paresthesias
Usually young adults with history of vigorous arm
activity
Inter-scalene Compression: triangle formed by the anterior, middle scalenes and 1st rib
Consider regions of attachment of scalene on cervical spine
Change of head position may exacerbate
Cervical trauma/MVA may predispose
Gangrene: most commonly in diabetes patients-feet; numbness doesn’t feel pain;
frostbitten
Costo-clavicular Compression
 Compression of neuro-vascular tissue between 1st rib and clavicle.
 May be secondary to previously healed clavicular facture
 Shoulder strap, military posture or stooped shoulders may aggravate
 SCM, platysma
 Obesity-hard to treat
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Eden’s test: pull shoulders back and down- monitor radial pulse
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Pec. Minor-coracoid compression: aka Hyperabduction syndrome (wright’s)
positionally aggravated by abduction and working overhead. Sleep position may
be a factor
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Double crush: 2 sites of compression/irritation. 1 or the other alone-might be
asymptomatic, but together cause problems
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Addison’s Test: Monitor radial pulse- patient rotates towards same side (ant.
Scalene)
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Modified Addison’s test: same as above but patient rotates head (middle scalene)
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Allen Manuver: shoulder abduction; elbow flexed at 90°, radial pulse, patient
looks AWAY
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Eden Manuver test: extend arms, radial pulse, chin to chest
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Wright’s HyperAbduction: abduct shoulder, radial pulse, reproduction of
chief complaints, and amplification of radial pulse.
Scoliosis:
 Curvature of the spine ( pathological) named by the apex (most lateral aspect)
 Evaluate using Plum line
Types:
1. Nonstructural: postural, compensatory-leg length
2. Transient Structural Scoliosis: sciatic scoliosis-antalgia position(away
from pain)
Hysterical scoliosis: psychiatric
Inflammatory scoliosis: ovarian cysts, abscess, pancreatitis, appendicitis
3. Structural scoliosis: Idiopathic( cause poorly identified/unknown) * most
common
 Infantile: before age 3
 Juvenile: 3-puberty
 Adolescent: puberty to maturity
 Congenital: in utero
 Vertebral: spina bifida occulta, mesenchymal disorder, osteogensis
imperfecta-blue sclera, dwarfism-achondroplasia
 Vertebral: trauma- irradiation, surgery
 Extravertebral = burns, etc.
 Neuromuscular: polio, cerebral palsy
 Surgery: cardiac and pulmonary effects not just for cosmetic
means
Scoliometer: note what level you’re measuring indication of progression
Children-x-ray: P-A(b/c of scatter radiation dose)
Left hand and wrist: patient bone age (Greulick and Pyleatias)
Compare chronologic age with bone age
Ring epiphysis: hazy ring above and below vertebrae  halo mature
Risser sign: x-ray finding of zygapophysis growth
ASIS  PSIS complete maturity +5 (goes by 1/4s)
Bone age matters for window of progression
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Plum line from SP of T1 (measure from plum line to gluteal line)
Can do before and after to document a change
Want head to sit in center of bodyso thoracic curve may increase to make
“correction”
Adam’s sign: look for rib hump-scapular winging
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Ultrasound in utero-can see anatomical changes in spine(dev. of hemivertebrae,
wedged vert. incomplete closure, etc.)
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Cobb’s method: most superior and inferior segments that is inclined in the curve
parallel and perpendicular at point of intersection.
Clinically significant: < 10°, What is the apex? Used to name scoliosis. ROM will
determine if flexible, Lumbar curve normally flexible, Up to 5° factor of error
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0-20°: stable ( they say monitor, but treat)
20-40° Bracing
40-50° ?? Bracing isn’t really helpful here
> 50° Surgery (tethered cord-too much tension on meningeal system) heart
and lung
Milwaukee brace
Copes Brace: air/water bladder to push pressure
23 hrs. wearing 1 hr to shower exercise
New York brace: turtle brace
16 hr protocol: 8 hrs to go to school without wearing it.
Goal of bracing = to slow or halt progression
Duration: until skeletal maturity
All kids should be on exercise protocol
Lateral electric surface stimulation AC current, reduces muscle
contraction as effective as Milwaukee brace, 8 hrs/night muscle stim.
(less)- not a TENS unit DC current
Breakdown of skin- discontinue till healed.
Expensive: Brace = $ 2000, LESS $2000
Some kids have difficulty with motion control, vestibular balance,
discriminating place in space
Harrington Rod: posterior( less invasive) distracting on concave side
Staples: anterior
Never adjust into area of stabilization, adjust above and below
The Shoulder:
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Vulnerable tendons (large head of bicep; supraspinatus,
subachronial bursa)
 Bursa: inflamed synoval extrafluid symptoms at night (rule out
cancer)
Teninopathies:
 Tendinosis(formally known as tendonitis) is most commonly
degenerative collagen that results from repetitive
injury/overuse and is not primarily inflammatory
 May be secondary to mechanical disruption including shoulder
impingement
 Calcific Tendinopathy: may be a sign of impingment
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Painful arc in abduction (70-110°)
Have ROM but is painful (p. 102 in carnes
Tendonitis +Bursitis of Shoulder:
 Calcium into tissue when there is repetitive stress to joint
 Acute tendonitis- roof of bursa; calcific deposit and in tendinous fibers-severe
inflammation
 Chronic hardened calcified tissue
 Rotator Cuff Strain: injury to muscles resulting from trauma, overuse, or
impingment.
 Grade consistent with extend of injury (mild, moderate, severe)
Shoulder impingement:
 Repeated irritation or pinching of the biceps brachii or rotator cuff tendons as they
pass between the coracoacronmial arch and the greater turberosity of the
Humerus ( non-specific shoulder pain)
 Three progressive stages:
1. Edema and hemorrhage resulting from excessive overhead activities;
typical age is less than 25 yrs. Reversible with conservative treatment
2. Fibrosis and tendinopathy resulting from repeated episodes of
mechanically induced inflammation; typical age between 25-40 yrs;
conservative treatment can contain but not reverse the damage; shoulder
functions satisfactory during light activity but becomes symptomatic after
vigorous overhead use; excessive repetitive use or heavy lifting
3. Trophic changes in the rotator cuff, biceps, and adjacent bone leading to
tendon ruptures and alterations of the acromion and greater tuberosity;
progressive disability often leads to surgical intervention; typical age is
usually >40
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4 types of impingement:
1. Anterosuperior = primary mechanical impingement
2. Posterior superior = internal impingement
3. Subcoracoid= very rare
4. Spinoglenoid = suprascapular nerve
Adhesive Capsulitis: Frozen Shoulder
 Marked reduction in shoulder ROM due to adhesive capsulitis and
soft tissue contracture around the glenohumeral jt.
 4 stages:
1. Pre-adhesive: full or slight limited ROM; early synovitis
only see on arthroscopy; no adhesions, painful
abduction/external rotation at GH jt.; gradual onset of pain;
no stiffness, no decreased ROM, nearly impossible to
diagnose from other GH conditions
2. Acute adhesive synovitis: early adhesion formation in
axillary fold, painful arc-slight limitation in ROM; pain
constant and may radiate; jt begins to freeze up
3. Maturation stage: less inflammation, moderate reduction
of axillary fold; reduction in size of synovial capsule and
GH space. No pain at rest. Pain on motion, muscle atropy,
very stiff.
4. Chronic Stage: adhesions fully mature; extreme loss of
ROM
Treatment: Tear up adhesions and restore joint.
 Codman’s exercise: vigorously swing and pendulum swing. At least 8X daily;
take joint into painful range. Tears up soft tissue adhesions.
 Pendulum – passive motion beyond pain free range.
 Circular swing: elephant trunk): ↑ weight ↑ traction- stimulates more
mechanoreceptors.
 Pulley exercises
 Patient must be compliant
 Apley’s scratch test: supraspinatus tendon. Superior hand behind head. Reach for
opposite scapula.
Rotator Cuff Injuries:
 Tears: supraspinatus (empty can test)
 C5-supraspinatus press test: abduct to 90° vs resistance; isometric test; 90°
abduction internally; rotated 30°
 Codman’s drop arm test: passive abduction past 90
 Drop or have pt lower slowly
 Pain, hunching, or weakness is +
 Bicep rupture: Luddington’s test
 Palpate tendon as pt. contracts/relaxes bicep.
 Rupture if tendon does not contract
 Contractile mass of bicep-“popeye”
Biceps tendonitis:
 Speed’s test: elbow straight; pt flexes shoulder and supinates vs resistance
 Bicipital groove pain
Yergason’s Test:
 Elbow flexed
 Pt.supinates vs resistance
 Resists elbow extension
 Bicipital groove pain
Shoulder dislocation Tests:
 Bryant’s sign: Lower acillary fold on dislocated side
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Calloway’s sign: Tape measure around acromion process thru axilla; compare
R vs L; larger is dislocated!
Circumferential: Inflammation ↑ , Edema ↑ , Hypertrophy ↑ , Atrophy ↓ ,
Tumor ↑
Hamilton’s Test: Ruler touches both acromion and lateral humeral epicondyle
at same time.
Dugas Test: Hand to opposite shoulder, elbow to chest if pt is unable to do
this = dislocated
Mazions Should Manuver: starts like Dugus, but ends with flexion of shoulder
covering eyes with elbow.
Apprehension test: Facial Expression
Ant. Dislocate = abduction and external rotation P-A on GH jt.
Post. Dislocate = shoulder flexed, A-P on elbow.
RA:
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Inflammatory- red, hot swollen joints (stage 1)
Chronic autoimmune inflammatory disease resulting in symmetrical
joint pain and swelling as well as subsequent destruction of the
affected joints.
Begins with bilateral involvement of the PIP and MCP jts.
Early stages difficult to diagnose as symptoms vary or mimic other
disease processes.
Pannus Formation: hyperplasia growth into joint. Infiltration of
synoval fluid, erosive, white cells microvilli, vascular components
(stage 2)
Age varies: adult onset is the most common,
Females in 30s
Juvenile RA due to infection, rashes, etc.
Exact etiology unknown (genetic component?)
Cold lesion (stage 3)
Stage 4: complete anklosis – fusion of jts.
Cervical involvement common- C1-2 instability
RA in hands- likes PIP Bouchard’s Nodes
Seal fin deformity: ulnar deviation
Swan Neck deformity
Boutonniere deformity-thumb; flexion of PIP and extension of DIP
Early prevention: atrophy of muscles in hands- not able to move
jointas it was designed to do.
Nodules: adjacent to bursa, can appear in lungs
Baker’s cysts: synovial cysts-knee synovium goes where it’s not
supposed to.
Rupture of extensor tendons- no function
RA nodule on ribs looks like bronchial carcinoma-biopsy needed.
Chiropractic Care for RA
o Stress management
o Nutrition-remove processed foods, allergies, and increase
vit. C intake
o Moist heat
o Gentle ROM exercises
o Paraffin treatment
o Low force full body approach
Description
Jt. Symmetry
Alignment
Bone density
Erosion
Osteophytes
Periostitis
Example
Inflammatory
Symmetrical
Polyarticular
Abnormal
Poorly defined
Absent
Present
RA
Degenerative
Symmetrical
Monoarticular
Abnormal
Normal ↑
Present
Absent
DJD
Osteoarthritis: refers to synovial joints
 Progressive degenerative loss of articular cartilage and joint margin changes in
diarthrodial jts.
 Most common joint disease worldwide
 Joint space narrowing
 Bony sclerosis/ remodeling-white on x-rays
 Boney hypertrophy/osteophyte formation
 Sub chondral cyst formation (geodes)
 Wolff’s law: increase density where stress occurs
 Primary due to wear and tear
 Genetic component
 Repetitive or frank trauma; weighbearing/obesity to knees/hips
 Cartilage fatigue to fibrillation and fissure
 Subchondral bone receives brunt of load and is very pain sensitive
 Stiffness after rest; improves with warm and moderate use
 Pain aggravated by use relieved by rest
 More common in women
 DIP-Heberden’s Nodes
 PIP-Bouchards nodes
 Stiffness and pain may affect ability to use hands
Other notes:
 Stenosing tenosynovitis of abductor pollicus longus and extensor pollicus brevis
 De Quervain’s Disease:
 Mommy thumb- Finkeinsteins test
 Flexor of digits-trigger finger-palpate nodules
 Ganglionic cysts of wrist- synovial herniation
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Dupuytren’s contracture: idiopathic, mostly in males-middle aged
Deep fibrosis of connective tissue
Paraffin wax treatment, passive mobilization, hand webb.