Evaluation In Patients With Joint Disease

Some musculoskeletal disorders affect mainly the joints and cause arthritis. Other primarily relate to the bone (eg. B. fractures, Paget’s disease of the bone, tumors), muscles or the extra-articular soft tissues (eg. B. fibromyalgia) and the periarticular connective tissue (eg. As bursitis, tendinitis, ligament strain). Arthritis can have numerous causes: infection, autoimmune diseases, deposit induced inflammation and minimal inflammatory Knorbel- and bone disorders (such as osteoarthritis.). The arthritis can affect, with a symmetrical or asymmetrical pattern of involvement of a (monoarthritis) or several joints (polyarthritis). Joints may be affected by fractures or sprains (see elsewhere in the MSD Manual). History The clinician should focus both on systemic, extra-articular and joint-related symptoms. Symptoms such as fever, chills, malaise, weight loss, Raynaud’s phenomenon, skin and mucous membrane findings (eg. As rash, photosensitivity, eye redness), and gastrointestinal and cardiopulmonary symptoms and findings may be associated with various joint diseases. Pain is the main symptom of diseases of the joints. The history should check character, localization, severity, pain and analgesic reinforcing factors as well as the time frame (new inserting or recurrent). It must be determined whether the pain when moving the start or after prolonged stress is worse, and if he is present when you wake up or developed in the course of the day. Normally an outgoing of superficial structures pain is better to locate as a pain deeper origin. Pain arising in the distal small joints is better to locate as the pain in the proximal large joints. In the joint verspürter pain can radiate from extra-articular structures or other joints. The arthritis often causes drilling, neuropathy rather burning pain. A rigidity as described refers to the difficulty of moving a joint, may mean weakness, fatigue, or fixed restriction of movement for the patient as well. The physician must distinguish a real joint blockade of movement due to pain avoidance. Rigidity characteristics can indicate the following causes: movement-related symptoms that occur when attempting to move a joint after a break again, speak for a rheumatic disease. The stiffness is more pronounced and prolonged with increasing severity in joint inflammation. The theater sign (short duration stiffness when getting up after several hours of sitting requires slow walking) is common in osteoarthritis. Morning stiffness in the peripheral joints holding> 1 h can be an important Frühymptom of joint inflammation, as in rheumatoid arthritis (RA), psoriatic arthritis or chronic viral arthritis, represent (s. Distinguishing characteristics of inflammatory and non-inflammatory joint diseases). Morning stiffness in the lower back, holding> 1 h can go back to a spondylitis. Fatigue is a desire for rest, indicating exhaustion. They must be distinguished from weakness, immobility and movement avoiding due to pain. Fatigue can be an expression of a systemic inflammatory disease. Instability (protrusion of a joint) suggests a weakness of the bands or other components of the support apparatus, it is checked by stress tests during a physical examination. A bulge is noted most frequently in the knee joint, resulting mostly from the inner joint defects. Distinguishing features of inflammatory and non-inflammatory joint diseases feature flammable non-flammable Systemic symptoms Striking, incl. Fatigue Exceptional beginning Slinky Usually several joints on successive one joint or several joints, morning stiffness> 1 hour <30 min Worst time of day morning During the day impact of activity on the symptoms (joint pain and stiffness) decline with activity aggravation after periods of rest also pain when moving deterioration in activity decline at rest Medical Examination Each affected joint should be inspected and palpated, and it should be the ranges of motion are measured , In polyarticular disease specific nichtartikuläre findings (eg. As fever, rash or fatigue) may indicate a systemic action. the rest position of the joint, and also any redness, swelling, deformity or skin abrasion and puncture sites are noted. Affected joints are compared with the non-affected joint the opposite side or the examiner. The joints are carefully palpated on tenderness, warmth and swelling. It is especially important to determine whether the pressure pain projected on the joint itself or periarticular structures such as tendons or bursa. It searches for an increase in the soft tissue, protrusions or tissue in columns and cavities (z. B. effusion or synovial proliferation). Palpation of swollen joints can sometimes distinguish between effusion, thickening of the synovium and bony outgrowths or capsule-related. Small joints (eg. As acromioclavicular, tibiofibular, radioulnar) are sometimes the source of pain that were initially localized in neighboring large joint. The increase of bone substance (often by osteophytes) should also be investigated. First, the active range of motion (maximum range of movement) must be investigated; a limitation may be on weakness, pain or stiffness, but also due to mechanical obstacles. Then, the passive mobility (maximum range of motion in the joint, by moving by the examiner) is detected; a limitation of the passive mobility typically reflects mechanical obstacles (eg. as by scar formation, swelling, deformity) as pain and weakness. The active and passive movement of an inflamed joint (z. B. due to infection or gout) can be very painful. The inability to provoke the pain with movement or palpation of the joint, the possibility of referred pain should be considered. The forms of joint involvement must be observed. A symmetric involvement of multiple joints is common in systemic diseases (such as RA.); monartikuläre (having a hinge) or asymmetric oligoarticular (containing ? 4) joint involvement is common in osteoarthritis and psoriatic arthritis. Small peripheral joints are commonly affected with RA, and the larger joints and the spine are more concerned with spondyloarthropathies. However, in the early stages of the disease the complete pattern of participation may be unclear. In the investigation crepitus, d can. H. a tactile or audible grinding under agitation, are detected. It can be caused by a roughened surface of cartilage or ligaments; the type of movement, through which the sound is generated, allows conclusions to the affected structures. In the joints is to search for specific findings. Elbow swelling and thickening caused by the disease of the elbow joint, are most likely determine laterally between the radius head and olecranon with visible protrusion. It must be examined whether a full 180 ° -Streckung is possible. While not flammable or extra-articular problems such as tendonitis not prevent full extension, is a limiting an early indication of arthritis. The area around the joint to be examined for swelling. Rheumatoid nodules of thick consistency can v. a. be found on the extensor side of the forearm. Sometimes tophi can be observed as a cream-colored units under the skin, they point to a gout. They can occur in the context of trauma, infection, gout and an RA. Swelling of the Bursa olecrani with cystic structure show up over the top of the olecranon, they do not hinder the movement. epitrochleare nodes can over the medial epicondyle be palpable, caused by inflammation of the hand, but also by sarcoidosis or lymphoma. Like the elbow to investigate are The investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital. var model = {videoId: '4545789939001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4616488704001_vs-564a45f8e4b071da27757601-767904724001.jpg?pubId=3850378299001&videoId=4545789939001' title: "How to study the elbow ', description:' ', credits:' the investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital ', hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true }; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Shoulder Since pain in the shoulder region can also be caused by radiation, a palpating investigation has the glenohumeral (shoulder), the acromioclavicular and sternoclavicular joint, the coracoid and acromialis, the clavicle, the subacromial bursa, the biceps tendon, which Tuberositiden of humerus and neck include. An effusion in the glenohumeral joint can cause a bulge between the coracoid process and humeral head. Possible causes are a RA, osteoarthritis, septic arthritis, a Milwaukee-shoulder (Basic calcium phosphate form of crystal) and other arthropathies. As one examines the shoulder The investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital. var model = {videoId: '4604999736001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4605064355001_vs-56425897e4b09297dff23419-672293880001.jpg?pubId=3850378299001&videoId=4604999736001' title: 'How to research the shoulder', description: '', credits: 'the investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital', hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true} ; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Restriction of movement, weakness and pain caused by damage to the rotator cuff can be identified quickly by the patient to abduct the arm lift over his head and then be lowered slowly. Specific maneuvers against resistance can help in clarifying the question of which tendons are affected. It should also to muscular and neurological abnormalities werden.Knie sought major changes such as swelling (z. B. effusion, Baker's cyst), atrophy of the quadriceps or joint instability are not difficult to determine at the knee when the patient stands and walks. In the upright position of the patient by the investigator to patella femoral condyles, tibial tuberosity, tibial plateau, fibula, medial and lateral joint space, popliteal fossa and quadriceps and patellar tendons should be palpated. The two columns correspond to the joint position of the two menisci; should be palpated during slow flexion and extension of the joint here. It must be differentiated by actual disturbances in the joint painful extra-articular bursae (z. B. anserina Bursa below the medial joint space). How to examine the knee is The investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital. var model = {videoId: '4604999739001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4605075640001_vs-564258f4e4b09297dff23423-672293877001.jpg?pubId=3850378299001&videoId=4604999739001' title: 'As the knee is to investigate' description: '', credits: 'the investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital', hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true }; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); The detection of small knee effusions is often difficult and is best done using the Ausbuchtungszeichens. The knee is fully extended and the leg slightly rotated outwardly while the patient is relaxed muscles in the supine position. The medial border of the knee is forced to move liquid from there. If an effusion is available, the placement of a hand on the suprapatellar sac and a simultaneous slight shock or pressure on the lateral joint gap may produce a visible liquid wave or bulging. Larger effusions can be identified visually or by balloting the patella. Many diseases of the joints, incl. RA, gout, osteoarthritis, or trauma can cause a Kniegelenkerguss. Flexion contractures can be found while attempting a full 180 ° -Streckung the joint. The patella is a free, painless mobility to untersuchen.Hüfte The investigation begins with a gait analysis. A significant coxarthritis often leads to limp, and this may be due to pain, leg shortening, flexion contracture, muscle weakness or knee problems. Limitation of internal rotation (an early sign of hip osteoarthritis or -arthritis) of flexion, extension or abduction are easy to find. By placing a hand on the iliac edge can be ruled out that pelvic movements simulate a good mobility of the hip joint. Flexion contractures can be identified by the extension of the hip joint while maximal bending of the opposite side is examined (for pelvic stabilization). A tenderness over the greater trochanter rather places an extra-articular bursitis close as intraarticular cause. By contrast, pain with passive movements (internal and external rotation in an upright position at 90 ° of flexion of the hip and knee) are an indication of failure of the hip joint. However, patients may have the same intra-articular and extra-articular disorders. How to examine the hip is The investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital. var model = {videoId: '4611394848001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4611418405001_vs-564635f1e4b0029fef682787-782203288001.jpg?pubId=3850378299001&videoId=4611394848001' title: 'As the hip is to investigate' description: '', credits: 'the investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital', hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true }; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Other joints Examination of the hand is presented elsewhere (overview and evaluation of diseases of the hand and pain in multiple joints). The investigations of the foot and ankle are shown in overview of diseases of the feet and ankles, the examination of the neck and spine in evaluation of neck and back pain. How to examine the wrist is The investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital. var model = {videoId: '4611398768001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4611411620001_vs-564635d1e4b071da27755b89-782203294001.jpg?pubId=3850378299001&videoId=4611398768001' title: 'As the wrist is to investigate' description: '', credits: 'the investigation was shown by Paul Liebert, MD, Tomah Memorial Hospital', hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true }; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Tests laboratory tests and imaging often provide less information than the medical history and clinical examination. Although some studies may be warranted in a patient, this often does not apply to an extensive investigation. Blood tests should be chosen on the basis of medical history and examination findings. However, blood tests, although there are no specific studies, some of the following tests can help in the search for particular system disorders: antinuclear antibodies (ANA) and anti-double stranded DNA antibodies in SLE rheumatoid factor and anti-cyclic-citrullinated peptide (anti-CCP) antibodies in RA HLA-B27 at spondyloarthropathy (z. B. at symptoms of inflammatory back pain and normal X-rays) antineutrophil cytoplasmic antibodies (ANCA) in certain vasculitides (sometimes useful in suspected systemic involvement) in contrast, leukocyte, the ESR and CRP provide evidence of an inflammatory genesis of arthropathy (z. B. in system disease or infection), but have no significant specificity or sensitivity. For example, have increases of ESR and CRP indicate a articular inflammation, but can also occur in many non-related joint inflammation (eg. As infection, cancer). In some inflammatory diseases, these markers do not erhöht.Bildgebende investigations These tests are often unnecessary. In particular, X-rays show v. a. While most joint diseases initially provide bony abnormalities no pathological bony findings. However, early localized, initially unexplained, persistent and severe pathological findings in the joint, or more commonly of the spine can be detected by imaging, such. , Primary tumors or bone metastasis, osteomyelitis, bone infarcts, periarticular calcification (e.g., as in a calcifying tendinitis), and other deeper findings that escape the physical examination. Suspicion of RA, gout or arthritis possibly erosions can prove cysts and / or joint space narrowing with osteophytes changes. When pseudogout possibly Kalziumpyrophosphatablagerungen show in intra-articular cartilage. In musculoskeletal diseases radiographs are first to make, but they are often less sensitive, particularly in the early stages of a disease as MRI, CT or ultrasonography. MRI provides the most accurate findings in microfractures that are not visible on the radiograph (v. A. Hips and pelvis), and also in soft tissue and internal pathological findings in the knee joint. CT should be used in case of unavailability or contraindication to MRI. In certain indications ultrasound, arthrography, scintigraphy and biopsies of bone, synovium and other tissues may additionally useful sein.Arthrozentese The Arhrozentese is the puncture of the joint with a needle to aspirate liquid. It can typically be used with existing effusion and correct implementation for the recovery and examination of the synovial fluid. The investigation of the synovial fluid is the most accurate way to rule out infections, arthritis induced deposition to diagnose and determine the cause of joint effusion. This method is indicated in all patients with acute or unexplained monarticular joint effusions and in patients with unexplained polyarticular joint effusion. is carried out as a arthrocentesis the knee. © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video. var model = {videoId: '4536722756001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4536733121001_4536722756001-vs.jpg?pubId=3850378299001&videoId=4536722756001', title: 'As a arthrocentesis the knee is carried out.', description: '' credits' © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video ', hideCredits: true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true};. var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Arthrocentesis shoulder. The shoulder joint is punctured while the patient is seated with the arm on the side and hand in her lap. The needle is inserted from the anterior, slightly inferior and lateral to the coracoid process, and advanced posteriorly in the direction of the joint socket. An access of posterior is also possible. is carried out as a arthrocentesis shoulder © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video. var model = {videoId: '4536722753001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4536730043001_4536722753001-vs.jpg?pubId=3850378299001&videoId=4536722753001', title: 'As a arthrocentesis the shoulder is carried out', description: '' credits' © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video ', hideCredits: true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true};. var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Arthrocentesis the elbow. The ulnohumerale joint is punctured while the elbow of the patient is flexed to 60 ° and the wrist is pronated. The needle is inserted on the lateral side surface of the joint between the lateral epicondyle of the humerus and the ulna. is carried out as a arthrocentesis the elbow. © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video. var model = {videoId: '4536717308001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4536730090001_4536717308001-vs.jpg?pubId=3850378299001&videoId=4536717308001', title: 'As a arthrocentesis the elbow is carried out.', description: '' credits' © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video ', hideCredits: true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true};. var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); The joint aspiration must be performed under strictly sterile conditions. Infections or rashes in the area of ??the puncture site are a contraindication. The containers for the samples should be prepared before the puncture. The puncture can be made with lidocaine or Difluorethanspray under local anesthesia. Many joints are dotted on the extensor side to avoid injury to nerves, arteries and veins, which are usually localized on the flexor surface of the joint. For most major joints einn 20-gauge needle can be used. Smaller joints of the upper and lower extremities are likely to be more accessible with a 22-G or 23-G cannula. It should be gained as much liquid as possible. Specific anatomical landmarks are used as aid (s. Arthrocentesis the shoulder., Arthrocentesis the elbow. Arthrocentesis and the knee.). is carried out as a arthrocentesis wrist © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video. var model = {videoId: '4536799007001', playerId 'H1xmEWTatg_default', imageUrl 'http://f1.media.brightcove.com/8/3850378299001/3850378299001_4536810258001_4536799007001-vs.jpg?pubId=3850378299001&videoId=4536799007001', title: 'As a arthrocentesis the wrist is carried out', description: '' credits' © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video ', hideCredits: true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true};. var panel = $ (MManual.utils.getCurrentScript ()) Closest ( 'video element panel..'); ko.applyBindings (model, panel.get (0)); Arthrocentesis the knee

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