Rheumatology

Podcast 032: Rheumatology With Dr Allan Sturgess

Some people light up joints and some people light up when they hear about joints. Although these are theoretically not mutually exclusive, rheumatologists tend to form the latter group.

In this episode, Dr Allan talks about rheumatology, interesting diseases in the specialty and what it’s like to win an award shaped like a foot.

Podcast

About the guest speaker

Dr Allan Sturgess is an Associate Professor of Rheumatology and specialist working in Sydney, Australia. He is the Department Head at St George Hospital.

Dr Allan enjoys hiking, reading and generally being rather awesome.

Music credits

Opening and closing blips by Lily Chen.

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Abdominal And Hip Signs In Children

There are many signs of peritoneal irritation.

Rovsing Sign

Palpation of the left lower quadrant elicits pain in the right lower quadrant.

Indication: suspected appendicitis, peritoneal irritation.

Obturator Sign

Passively flex the supine patient’s hip and knee and internally rotate the hip to elicit pain.

Indication: suspected pelvic appendicitis, irritation to obturator muscle.

Psoas Sign

2 options:

  1. Ask the supine patient to flex the hip against resistance to elicit pain.
  2. Ask the supine patient to roll onto their side and passively extend the hip, which stretches the psoas and elicits pain.

Indication: suspected retrocaecal appendicitis, irritation to psoas muscle.

Galeazzi Sign

Have the infant supine, with the hips at 45 degrees and knees at 90 degrees. Look at the height of the knees for asymmetry.

Indication: suspected hip dislocation or congenital femoral shortening.

McBurney’s Point

Pain at the point 1/3 along the line from the ASIS to the umbilicus.

ASIS means anterior superior iliac spine, not a government spy organisation.

That’s the lateral 1/3 point closest to the ASIS.

Indication: suspected appendicitis.

Dunphy’s Sign

When coughing equals pain.

Indication: suspected appendicitis.

References

  1. Gooding, F. (2018). Rovsing’s sign • LITFL • Medical Eponym Library. [online] LITFL • Life in the Fast Lane Medical Blog. Available at: https://lifeinthefastlane.com/eponymictionary/rovsings-sign/ [Accessed 8 Apr. 2018].
  2. MDforAll (2010). Obturator Sign. Available at: https://www.youtube.com/watch?v=jV80jcnhNtA [Accessed 8 Apr. 2018].
  3. MDforAll (2010). Psoas Sign. [image] Available at: https://www.youtube.com/watch?v=n0a0PCwsVQ4 [Accessed 8 Apr. 2018].
  4. Fulford, D. (2018). Galeazzi Test • LITFL • Medical Eponym Library. [online] LITFL • Life in the Fast Lane Medical Blog. Available at: https://lifeinthefastlane.com/eponymictionary/galeazzi-test/ [Accessed 8 Apr. 2018].
  5. Hardin, D. (1999). Acute Appendicitis: Review and Update. [online] American Family Physician. Available at: https://www.aafp.org/afp/1999/1101/p2027.html [Accessed 8 Apr. 2018].

Schober Test

Purpose

The Schober test checks the lumbar flexion range of motion.

Suppose the spine is straight. If it bends forward, like in lumbar flexion, the posterior surface of the back should stretch out to accommodate the movement.

For example, if you have a circle drawn with a thick line, the circumference of the outer side of the line is greater than the circumference of the inner side of the line.

If the posterior back doesn’t stretch out all that much, it means the range of lumbar flexion is limited.

Steps

  • Patient has back facing you
  • Find the level of the posterior superior iliac spine
    • PSIS is roughly at L5-S1 level
  • Make a mark 10cm above that and another mark 5cm below it
    • Memory aid: the higher number is higher up
    • The distance between the points is 15cm
  • Tell patient to touch toes
    • Patient bends over, which is lumbar flexion
  • If the distance between the points is <20cm, there is limited lumbar flexion
    • Alternatively, means the increase in distance from the lumbar flexion movement is <5cm

References

  1. Physiopedia. (n.d.). Schober test. [online] Available at: https://www.physio-pedia.com/Schober_test [Accessed 2 Feb. 2018].
  2. General Practice Notebook. (n.d.). Schober’s test. [online] Available at: https://www.gpnotebook.co.uk/simplepage.cfm?ID=1422917656 [Accessed 2 Feb. 2018].

Thomas Test

Purpose

The Thomas test looks for hip pathology, namely of issues with hip flexor tightness. This is called a fixed flexion deformity.

For example, there could be a problem with the iliopsoas muscle.

Steps

  • Patient is supine on bed
  • Tell patient to bring knees to chest
    • Patient flexes both knees and hips
    • But not excessively so, otherwise it could give a false positive result
  • Lower one leg straight onto the bed
    • If the thigh is on the bed, it is a normal result
    • If the thigh is off the bed, the patient has a fixed flexion deformity of that side

References

  1. Patel, M. (2011). Thomas test. [online] OrthopaedicsOne. Available at: https://www.orthopaedicsone.com/display/Main/Thomas+test [Accessed 31 Jan. 2018].
  2. Physical Therapy Haven. (2018). Thomas Test. [online] Available at: http://www.pthaven.com/page/show/157779-thomas-test [Accessed 31 Jan. 2018].
  3. General Practice Notebook. (n.d.). Thomas’ test. [online] Available at: https://www.gpnotebook.co.uk/simplepage.cfm?ID=120913935 [Accessed 31 Jan. 2018].

Regulators Of Bone Formation

Stimulates bone formation

Wnt: Wow! Let’s have bone formation!

Wnt proteins bind to LRP5 receptors on osteoblasts, triggering bone formation.

Inhibits bone formation

Sclerostin: Stop! No bone formation here!

Sclerostin is a factor produced by osteocytes. It inhibits the above Wnt process.

References

  1. Walker, B. R., Colledge, N. R., Ralston, S., & Penman, I. D. (2014;2013;). Davidson’s principles and practice of medicine (22nd ed.). Edinburgh: Churchill Livingstone/Elsevier.