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musculoskeletal > GALS screening > Flashcards

GALS screening Flashcards

1
Q

what does GALS stand for *

A

gait

arms

legs

spine

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2
Q

what is the GALS test used for *

A

it is a locomotor examination

it is a screening test to quickly determine if any of the joints are abnormal and which

if you can put the joint in a tight packed position - it means the chance that there is damage to that joint is low

look for the nature of the abnormality - is it inflammatory or mechanical

what is the extent (distribution) of the joint involvment eg rheumatoid arth is symettrical

are there any other features of diagnositic importance - any extra-articular features ie the butterfly rash in lupus

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3
Q

what are the key questions at the start of the GALS screening test *

A

have you any pain or stiffness in your muscles

can you dress yourself completely without any difficulty

can you walk up and down the stairs without any difficulty

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4
Q

what would someone with inflamm arth say when asked if they had pain *

A

pain worse in the morning around joints

takes them a while to get going

early morning joint stiffness is used to assess whether treatment is working

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5
Q

what do you look for in a gait assessment *

A

observe pt walking, turning and walking back

look for

  • smoothness and asymettry
  • normal stride length
  • ability to turn quickly

you are trying to spot the early signs

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6
Q

what are you looking for in the spine assessment *

A

is paraspinal and shoulder girdle muscle bulk symettrical

is the spine straight

are the iliac crests level

is gluteal muscle bulk normal

are there popliteal swellings

are the achilles tendons normal

are there signs of fibromyalgia - there are specific tender/trigger points - sqeeze over midpoint of each supraspinatous or of skinfold over the trapeius

are spinal curvatures normal - normally have cervical lordosis, thoracic kyphosis and lumbar lordosis

is lumbar spine and hip flexion normal - ask pt to bend forward and touch toes with knees straight

is cervical spine normal - place ear on shoulder ie lateral spine movement - difficult if inflammation so if you can do it there is no inflammation

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7
Q

what is an early sign of ankylosing spondylitis *

A

loss of lumbar lordosis - ie the spine becomes straight

no actual damage to the bones

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8
Q

describe the arms examination in GALS *

A

look for normal girdle muscle bulk nad symettry

look to see if full extension at the elbows

are shoulder joints normal - place hands behind head and push the elbows backk

examine hands palms down with fingers straight

observe supination, pronation, grip and finger movements - ask them to pronate and supinate with elbows flexed, place tip of each finger to tip of thumb and assess normal dexterity and precision grip

test for synovitis at MCP - MCP squeeze test - sequeeze across 2nd to 5th MCPjs - discomfort suggests synovitis eg in early rheumatoid arthritis

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9
Q

what is seen in the arm assessment in rheumatoid arthritis *

A

cant elbow extend, supinate, extend wrist, or do fine finger movement

have subluxation of the wrist and MCPjs so cant extend wrists or elbows and are stuck supinated

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10
Q

describe the legs assessment in GALS *

A

look for knee/foot deformity

assess flexion of hip/knee - pt lies on bed and you passively internally rotate each hip in flexion

look for knee swellings - examine each knee for signs of fluid by doing buldge sign and patella tap sign - push fluid into the knee and tap the patella - it becomes bouncy because it comes up

test for synovitis at MTP - MTP squeeze test

inspect soles of feet - for rashes and calluses - mechanical problems can occur as a result of the inflammatory ones

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11
Q

describe the locomotor examination *

A

detailed examination of any abnormal joints seen in GALS

  • inspection - swelling, redness, deformity
  • palpation - warmth, tenderness, crepitus
  • movement - active, passive, against resistance
  • function - loss of

what is the nature of the joint abnormality

  • inflamm
  • irreversible joint damage - eg deformities form long standing rheumatoid arthritis - once you ahve treated the inflammation, you want the joint to go back to normal, if it hasnt there is joint damage - might need surgery
  • is there a mechanical defect
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12
Q

what are the signs of inflammation *

A

swelling - tumor

warmth - calor

erythma - rubor

tenderness - dolor

loss of function - functio laesa

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13
Q

define arthritis *

A

definate inflammation of a joint ie swelling, tenderness and warmth of affected joints

eg in rheumatoid arthritis

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14
Q

define arthralgia *

A

refers to pain in joint(s) without demonstratable inflammation by physical examination

eg SLE - disorder of connective tissue so less visible inflammation

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15
Q

define dislocation *

A

articulating surfaces are displaced and no longer in contact

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16
Q

define subluxation *

A

partial dislocation - but some connection with articular surface

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17
Q

describe varus deformity *

A

lower limb deformity whereby the distal part is directed towards the midline eg varus knee with medial compartment osteoarthritis

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18
Q

describe valgus deformity *

A

lower limb deformity whereby distal part is directed away from the midline eg hallux valgus

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19
Q

define synovitis *

A

inflammation of the synovial membrane

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20
Q

describe gout

A

arthritis

tissue deposition of monosodium urate crystals occurs as a result of hyperurcaemia and leads to either gouty arthritis or tophi (eggagerated deposits of MSU in tissue)

because of too much purine in diet eg in red meat

effects 1st MTP and knee

has abrupt onset, is extremely painful, joint is red, warm, swollen and tender, resolves spontaneously over 3-10 days

if single joint could be gout or infection - rule out by aspiration

if in MTP can clearly be gout so dont have to aspirate the joint, if in knee should

otherwise give anti-inflammatory to treat gout which would worsen infection

long term treatment is to reduce uric acid by changing diet and introducing drugs

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21
Q

what can the site of swelling and tissue involved tell you about joint swelling *

A
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22
Q

what happens if you have swelling on the elbow *

A

cant bend it if there is fluid in the elbow joint

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23
Q

describe tenosynovitis with extensor tendon rupture *

A

synovium around the tendons is what is inflammed

if it is left = damage to the tendon = rupture - cant extend fingers

24
Q

describe enthesopathy *

A

pathology at the site where the ligament or tendon inserts into the bone

eg at achilles tendon or plantar fascia

do imaging to see where the swelling is

25
Q

what are the signs of irreversible joint damage *

A

joint deformity - malalignment of 2 articulating bones

crepitis - because of break down of articular cartilage = audible and palpable sensation of movement of 1 roughened surface over another, this is a classical feature of OA - palato-femoral crepitis on flexing the knee

26
Q

what joints does ankylosing spondylitis affect *

A

sacroiliac joints (sacroilitis) and spine - may lead to spinal fusion and deformity

there is increased thoracic kyphosis and loss of lumbar lordosis - because more comfortable

enthesis = chronic enthesopathy

non-axial joints - hips and shoulders common, others less frequently involved

27
Q

what are the signs of mechanical defect *

A

may be due to inflammation, degenerative trauma and identified by:

  • painful restriction of motion in absence of features of inflammation eg knee locking due to meniscal tear or bone fragment instability
  • instability - side to side movement of tibia on femer due to ruptured collateral knee ligaments
28
Q

how do you define the number of joints involved *

A

polyarthritis - >4 joints

oligoarth 2-4

monoarth 1

29
Q

what do you look for in pattern of arthritis *

A

number of joints involved

if involvement is symettrical

the size of the joints involved - small are hand and feet, big are hip and knee

is there axial involvement

30
Q

what is suggested by bilateral and symettrical involvement of large and small joints *

A

rheumatoid arthritis

31
Q

what is suggested by lower limb asymettrical oligoarth and axial involvement *

A

reactive arth

32
Q

what is suggested by exclusive inflammation of 1st metatarsophalangeal joint *

A

gout or infection

33
Q

what are the joints commonly affected,and not, by rheumatoid arthritis *

A

DIP has little synovium so is spared

cervical spine - synovium in axial joint between C1 and 2

34
Q

what are the joints affected or not in OA *

A

affected are weight baring/for dexterity

those spared can be involved in rare cases when there is genetic involvement for bone and cartilage or specific occupational histories

35
Q

what are the joints involved or not in polyarticular gout *

A
36
Q

extraarticular features visible in rheumatoid arthritis *

A

subcutaneous nodules on border of forearm where there are no joints

the immune complexes and rheumatoid factor cause inflammation out of the joints

37
Q

extra-articular features of gout *

A

tophi - subcut deposits of uric acid

indication had raised gout for a long time - have enough uric acid to be deposited outside of the joint

need to lower uric acid because likely to have repeated attacks of gout

38
Q

extra-articular features of lupus *

A

malar rash that spares the naso-labial folds due to sunlight exposure

39
Q

when would you do synovial fluid analysis

A

when you’re not sure what is going on and want to rule out infection

and what to know what is causing the infection so you know how to treat ie is it resistant/fungal etc

if chronic and not showing any of the signs of typical conditions - worry about infection eg TB and fungal - also do biopsy because need to be sure not infection otherwise make infection worse with anti-inflammatory treatment

also useful to confirm diagnosis in suspected crystal arthritis

40
Q

describe synovial fluid *

A

it is a viscous fluid present in joint spaces of synovial joints (diathroses) - colourless or pale yellow transparent viscous film covering synovium and cartilage with few cells

41
Q

what is synovial fluid synthesised by

A

synovial lining cells

42
Q

describe the structure of the synovium, relate this to the production of the synovial fluid *

A

consists of cells lining 1-3 cells deep in a matrix containing type 1 collagen and proteoglycans

there are 2 types of synovial lining cells - type A are macrophage like and type B are fibroblast like

type B secrete the hyaluronic acid that results in the viscocity of synovial fluid

43
Q

describe abnormal increase in synovial fluid volume *

A

called synovial effusion

abnormal mechanical stimulation eg in osteoarthritis with damage to cartilage and bone = increased production of hyaluronic acid by fibroblasts due to mechanical forces

excess hyaluronic acid increases oncotic pressure = increase in synovial volume to return composition to normal

in synovitis due to inflammation the effusion is inflamm exudate = abnormal composition of inflammatory cells and mediators and reduced hyalyuronic acid

this is typical for acute monoarthritis for large joints

44
Q

describe the different compositions of synovial fluid depending on state *

A

normal is clear/pale yellow and viscous

non-inflamm to inflamm to infectious gets more turbid and almost like pus

number of white cells increases too

45
Q

how is arthrocentesis performed

A

needle aspiration under aseptic conditions

46
Q

what are the contraindications of arthrocentesis

A

conditions or disorders that increase bleeding into joint

overlying skin infection because risk of introducing infection into joint

47
Q

possible complications of arthrocentesis

A

rare

introducing infection

haemarthitis

damage to structures in joint - ie cartilage

48
Q

describe teh synovial fluid examination

A

rapid gram staining followed by culture and ab sensitivity assays

polarising light microscopy to see crystals which can be seen in arthritis due to gout or pseudogout - only can differentiate them by looking at the crystals

49
Q

management of septic arthritis *

A

AB therapy - joint destruction can happen rapidly so emergancy

joint washout for large joints because still have MMP enzymatic activity that can mediate joint damage

ask what caused the infection - ie look at suseptibility factors

  • impaired hsot defence in elderly and young, chronic illness eg dm, liver disease, HIV infection, immunosuppressive meds eg corticosteroids
  • direct penetration - invasive procedures/drug use
  • joint damage - prosthetic joints eg rheumatoid arthritis
50
Q

summarise connective tissue disorders *

A

arthralgia and arthritis is non-erosive typically

serum auto-ab are characteristic and may aid diagnosis, correlate with disease activity, may be directly pathogenic

rayneud’s phenomenon is characteristic

  • have intermittent vasospasm upon exposure to cold
  • typical colour changes - vasospasm causes blanching to white, blue with cyanosis as static venous blood deoxygenates, then red with reactive hyperaemia
  • doesnt affect thumb
  • not symettrical
  • gets better when warm
  • in connective tissue disease severity increases - so can happen with trivial changes in temperature

(raynauds is commonly isolated and benign, but if you have thse conditions you are likely to have raynauds)

51
Q

clinical manifestations of lupus *

A

typically diagnosed in patients between 15-45years

malar rash

mouth ulcers

hair loss

raynauds

arthralgia and sometimes arthritis

serositis - pericarditis, pleuritis, less commonly peritonitis

renal disease - glumerulonephritis - lupus nephritis

cerebral disease - cerebral lubus eg psychosis

52
Q

describe sjogren’s syndrome *

A

autoimmune exocrinopathy - causes destruction of the exocrine glands - there is lymphocytic infliltration of exocrine glands and other organs

can be isolated or associated with SLE - termed secondary sjogrens if paired

typically diagnosed in middle age female

females more than males

dry eyes - xenophthalmia, dry mouth - xenostomia, parotid gland enlargement

damage to teeth because of problems with salivary glands

damage to cornea because dont form the protective layer of tears

commonest extraglandular manifestations are non-erosive arthritis and raynaud’s phenomonan

has anti-ro adn anti-la ab and rheumatoid factor

53
Q

describe inflammatory muscle disease

A

proximal muscle disease due to autoimmune mediated infiltration either with (dermatomyositis) or without (polymyositis) a rash

skin changes in derm

  • lilac colured rash (heliotrope) on eyelids, malar region and naso-labial folds
  • red/purple raised or flat lesions on knuckles (gottron’s papules)
  • subcutaneous calcinosis
  • mechanic’s hands - fissuring and cracking of skin over finger pads

ANA - anti-tRNA synthetase Ab

elevated cpk, abnormal electromyography, abnormal muscle biopsy (polymyositis, CD8 T cells, derm CD4 and B cells)

associated with malignancy and pul fibrosis

54
Q

describe systemic sclerosis

A

vasculopathy - raynauds - can get digital ischemia if you dont get control of raynauds

thickened skin with raynauds - dermal fibrosis, cutaneous calcinosis, telangiectasia

skin changes may be limited or diffuse

Diffuse systemic sclerosis:

  • Fibrotic skin proximal to elbows or knees (excluding face and neck)
  • Anti-topoisomerase-1 (anti-Scl-70) antibodies
  • Pulmonary fibrosis, renal (thrombotic microangiopathy) involvement
  • Short history of Raynaud’s phenomenon

Limited systemic sclerosis (limited to certain areas) :

  • Fibrotic skin hands, forearms, feet, neck and face
  • Anti-centromere antibodies
  • Pulmonary hypertension
  • Long history of Raynaud’s phenomenon
55
Q

describe overlap syndrome

A

when features of >1 connective tissue disoprder are present

when incomplete features of a connective tyissue disease is present - called undifferentiated connective tissue disease

musculoskeletal (12 decks)

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