Professional Documents
Culture Documents
OA
OA
History taking
**shortening in unilateral OA
4. Differential diagnosis
● Infection (2 types)- Bacteria and TB (TB must separate out due to endemic)
Rheumatoid arthritis-
- pain& stiffness of small joints of hand(fingers) last for >1hr >2weeks: must be
symmetrical (bilateral).
- pain is symmetrical
Gout- acute pain/inflammation at 1st metatarsal phalangeal joint at big toe (podagra
joint), any treatment receive for gout?
1. Inspection
2. Palpation
3. Movement
4. Special test
● Ask patient to walk (must take off shoes)- heel strike, stance and swing
- shoulder of affected site drop because of varus of knee = short limb gait
>>deformity
● Ask patient stand again with both foot together-inspect from front, side, back
Infront- see knee varus deformity and gap between knee (measure the gap from
medial condyle with measuring tape).
**if see baker cyst, diagnosis straight OA, baker cyst is complication of OA
General inspection-hand any nodules at PIP & DIP and elbow, palm, eyes,
temporal muscle wasting etc.
⮚ Knee: Medial parapatella gutter, if not seen (effusion) **OA normally seen. If
no gutter then do fluid shift test.0
⮚ Below knee: Gastronecmius (media) and peronous (lateral) muscle atrophy
2. Palpation
Superfical for temperature and soft tissue, deep for bone. Suprapatellar, patellar
and infrapatellar region.
(sit on patient foot, knee flexed 90o) 4 fingers behind, thumb center.
Start from tibia crest, use 2 thumbs palpate tibia crest from distal to proximal until
reach tibia tuberosity( eyes at pt face), > at level of tibial tuberosity- right thumb
palpate medially til pes anserinus (gracilis, semitendinous, sartorius) look for
tenderness (if tender=RA and AS) > back to tibia tuberiosity> left thumb move
laterally reach fibulla head for tenderness(if tender=RA) > back to tibia
tuberiosity> move up from tibia tuberiosity to soft tissue( patella tendon) > palpate
medial and lateral side will be soft ( area of joint line) then keep palpating to
medial and lateral will feel something hard which is the collateral ligmaments.
right thumb move medially from soft tissue til hard (collateral ligamament)
(usually OA tender at medial joint space)> back to centre> left thumb moves
laterally to collateral ligaments> go up to patella to feel for patella
Passive is start from the point that patient cannot do further active movement, (OA
cannot flexed)
*OA fixed flexion is due to soft tissue, so passive movement can further flexed.
Thickened knee capsule (soft tissue not bone) - stiffness, so cannot flex actively
but can flex further passively because the capsule is soft.
*If cannot fuether flexed by passive, due to knee ankylosis secondary to septic
arthritis (bone issue)
4. Special test (only do at the affected side), supine, bring foot together.
Bring the foot together, check got gap, Use both thumbs dorsiflex the foot
Look the heel, if heel lower/ higher means shortening. If got shortening on the heel,
do galleazi test. Flex knee 90 degree. Put ruler on knee See from tibia side if got
shortening then it means tibia shortening. See from femur side, if got shortening
from that side means it’s a femur shortening.
Left hand push from suprapatellar (block the space, don’t release hand), left thumb
place on lateral joint space
Right hand shift fluid from medial to lateral. Lift right hand first. Will see a
depression. shift the fluid again from lateral to medial with your thumb.
Patellar tap- done when the patellar is hugely swollen. Not done in OA.
● Patella grinding test- supine or sitting.( knee in full extension and sitting)
Supine: Passive grinding test- palm push on patella, elbow extended, move patella
in circular motion.
Sitting: knee is flexed 90 degerees. palm push patella, elbow extended. Other hand
extend and flex knee. Can also feel for crepitus.
Left hand hold ankle, right hand press patella, left hand extend& flexed legs
See from front, put phone above suprapatella, if tilted= tibia shortening
See from above, put phone above infrapatella, if tilted= femur shortening
Investigation
1. Laboratory- routine blood test ( FBC, LFT, RP, FBS only in older people) ,
Inflammatory markers ( tro infection and tumor: ESR, CRP-crp more important
and sensitive), tumour markers ( not imp in OA)
2. Imaging-
● Xray of knee AP, lateral in standing position (4+1 features) Calgrins and
Lawrence classifcation. Calgrins type 4 is with deformity and reduced joint
space. Type 3: reduced joint space. Type 1: Only pain. no reduced joint space
and no osteophyte. Type 2: got osteophyte.
⮚ Subchondral sclerosis
⮚ Subchondral cyst
⮚ Osteophyte
Treatment
Non operative
- Ultrasound wave
- Heat therapy
Operative