Tissue deposition of monosodium urate (MSU) crystals Result of hyperuricaemia Can lead to gouty arthritis and tophi (aggregated deposits of MSU in subcutaneous tissue)

8. The GALS screen Flashcards by Yash Kapoor

What does GALS stand for?

Gait
Arms
Legs
Spine

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What is the GALS screen?

Initial rapid joint screening examination

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How do we screen for gait?

Observe patient walking, turning and walking back, looking for:
• Smoothness and symmetry of leg, pelvis and arm movements
• Normal stride length
• Ability to turn quickly

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How do we screen the spine?

Observe the spine and ask yourself the following questions:
• Symmetrical para-spinal and shoulder girdle muscle bulk?
• Straight spine?
• Normal gluteal muscle bulk?
• Popliteal swellings?
• Normal Achilles tendons?
• Signs of fibromyalgia?
• Normal spinal curvatures?
• Normal lumbar spine and hip flexion?
• Normal cervical spine?

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How do we screen the arms?

Look for normal girdle muscle bulk and symmetry
Check for full extension at the elbows
Normal shoulder joints?
Observe supination, pronation, grip and finger movements
Test for synovitis at the MCP joints

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How do we screen the legs?

Look for knee or foot deformity or swelling
Assess flexion of hip and knee
Look for knee swellings
Test for synovitis at the MTP joints
Inspect soles of the feet

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What do we do once the GALS screen is completed?

Locomotor examination - detailed examination of any abnormal

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Describe the detailed examination of abnormal joints

Inspection - swelling, redness, deformity
Palpation - warmth, crepitus, tenderness
Movement - active, passive, against resistance
Function - loss of it

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What does arthralgia refer to?

Pain within a joint without demonstrable inflammation by physical examination

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What is subluxation?

Partial dislocation

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What is a varus deformity?

Lower limb deformity

* Distal part is directed towards the midline

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What is a valgus deformity?

Lower limb deformity

* Distal part is directed away from the midline

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Where is acute gout typically seen in arthritis?

First metatarsal-phalangeal joints

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What causes gout?

Tissue deposition of monosodium urate (MSU) crystals
Result of hyperuricaemia
Can lead to gouty arthritis and tophi (aggregated deposits of MSU in subcutaneous tissue)

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When does gout usually resolve?

Spontaneously over 3-10 days

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What are the 3 signs of irreversible joint damage?

Joint deformity e.g. mal-alignment
Crepitus
Loss of joint range or abnormal movement

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What are spondyloarthripathies?

• Group of conditions where rheumatoid factor comes back negative
• Includes:
- reactive arthritis
- Reiter's syndrome
- ankylosing spondylitis
- psoriatic arthritis
- enteropathic synovitis

What questions do you ask yourself to determine the type of arthritis (when looking at the joints)?

Number of joints involved
Symmetrical?
Size?
Axial (spine) involvement?

How do you classify arthritis by the number of joints involved?

Monoarthritis - single joint
Ligoarthritis - 2-4 joints
Polyarthritis - >4 joints

Which type of arthritis is bilateral and symmetrical involvement of large and small joints typical of?

Rheumatoid arthritis

Which type of arthritis is lower limb asymmetrical oligo-arthritis and axial involvement typical of?

Reactive arthritis

What condition is exclusive inflammation of the first metatarsophalangeal joints highly suggestive of?

Gout

Which type of arthritis is the exclusive inflammation of the distal interphalangeal joints of the fingers suggestive of?

Psoriatic arthritis

Which joints are commonly involved in polyarticular gout?

First MTP
Ankle
Knee

What is an abnormal increase in synovial fluid termed as?

Synovial effusion

What happens to the production of hyaluronic acid if there is abnormal mechanical stimulation?

* Increased production by synovial fibroblasts | * This increases oncotic pressure and synovial volume - normal composition

What happens to the production of hyaluronic acid in inflammation?

* Effusion is inflammatory exudate * Inflammatory cells, mediators => reduced hyaluronic acid * Abnormal composition * More neutrophils - still more viscous

Why is it important not to confuse gout with an infection?

Bacteria release metalloproteinases which destroy the articular cartilages

How is the synovial fluid examination performed?

Needle aspiration under aseptic conditions (arthrocentesis)

What are the contraindications and possible (rare) complications of arthrocentesis?

* Conditions that increase risk of bleeding into joint * Overlying skin infection * Bleeding into joint * Risk of introducing infection e.g. creating a septic arthritis * Damage to structures within the joint e.g. cartilage

What are synovial fluid samples routinely examined for?

* Pathogens - rapid Gram stain followed by culture and antibiotic sensitivity assays * Crystals - polarising light microscopy for detection

What is Raynaud's phenomenon?

* Intermittent vasospasm of digits on exposure to cold * Can be normal, but is over-represented in connective tissue disease * White => blue => red * Cyanosis as static venous blood deoxygenates * Reactive hyperaemia as blood flow increases

What is Sjörgen's syndrome and the effects of it?

• Connective tissue disease • Destruction of exocrine glands - autoimmune exocrinopathy • Associated with Anti-Ro/La and Rheumatoid factor • Results in: - dry eyes (xerophthalmia) - dry mouth (xerostomia) - parotid gland enlargement • Extra-glandular manifestations - non-erosive arthritis and Raynaud's • Secondary if it occurs in the context of another CTD

What is the inflammation of the muscle with and without skin involvement called?

* With - dermatomyositis | * Without - polymyositis

What are the skin changes in dermatomyositis?

* Lilac-coloured (heliotrope) rash on eyelids * Red or purple flat or raised lesions on knuckles (Gottron's papules) * Subcutaneous calcinosis * Mechanic's hands (fissuring and cracking of skin over finger pads)

Which autoantibodies is the inflammatory muscle disease changes associated with?

ANA - anti-tRNA synthetase antibodies

What are the following like in muscle inflammatory disease tests: • CPK (creatine phosphokinase) • Electromyography • Muscle biopsy

* Elevated CPK * Abnormal electromyography * Abnormal muscle biopsy (polymyositis = CD8+, dermatomyositis = CD4+ and B cells)

What does systemic sclerosis attack?

Skin, causing dermal fibrosis (very rare)

What happens in diffuse (referring to skin changes) systemic sclerosis?

* Fibrotic skin proximal to elbows or knees * Anti-topoisomerase-1 antibodies * Pulmonary fibrosis, renal involvement * Short history of Raynaud's phenomenon

What happens in limited (referring to skin changes) systemic sclerosis?

* Fibrotic skin hands, forearms, feet, neck and face * Anti-centromere antibodies * Pulmonary hypertension

What is overlap syndrome?

When feature of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease

What does mixed connective tissue disease (MCTD) refer to?

* Patients with features seen of SLE, scleroderma, rheumatoid arthritis and polymyositis * All with the presence of anti-U1-RNP antibody