Musculoskeletal 8 - The Gals Screen Flashcards
1
Q
What is the gals examination?
A
- Screening test designed to be quick and determine if nay joints are abnormal
- Gait (observe patients walking, turning and walking back)
- Arms
- Legs
- Spine
2
Q
What do you look for when assessing gait?
A
- Smoothness and symmetry of leg, pelvis and arm movements
- Normal stride length
- Ability to turn quickly
3
Q
What do you look for in the spine?
A
- Is paraspinal and shoulder girdle muscle bulk symmetrical?
- Is the spine straight?
- Are the iliac crests level?
- Is the gluteal muscle bulk normal?
- Are the popliteal swellings?
- Are the Achilles tendons normal?
- Are there signs of fibromyalgia?
- Are spinal curvatures normal?
- Is lumbar spine and hip flexion normal?
- Is cervical spine normal?
4
Q
What do you look for in the arms?
A
- Look for normal girdle muscle bulk and symmetry
- Look to see if there is full extension at the elbows
- Are shoulder joints normal?
- Examine hands palms down with fingers straight
- Observe supination, pronation, grip and finger movements
- Test for synovitis at the metacarpo-phalangeal joints (MCP joints - squeeze test)
5
Q
What is looked for in the legs?
A
- Look for knee or foot deformity
- Assess flexion of hip and knee
- Look for knee swellings
- Test for synovitis at the metatarso-phalangeal joints (MTP joints)
- Inspect soles of the feet
6
Q
How are abnormal joints examined?
A
- Inspection: swelling, redness, deformity
- Palpation: warmth, crepitus, tenderness
- Movement: active, passive, against resistance
- Function: loss of function
7
Q
How is the nature of the joint abnormality assessed?
A
- Is there inflammation? (swelling, warmth, erythema, tenderness, loss of function)
- Is there irreversible joint damage?
- Is there a mechanical defect?
8
Q
What is arthritis?
A
Definite inflammation of a joint(s) i.e. swelling, tenderness and warmth of affected joints
9
Q
What is arthralgia?
A
Refers to pain within a joint(s) without demonstrable inflammation by physical examination - seen in lupus
10
Q
What is dislocation?
A
Articulating surfaces are displaced and no longer in contact
11
Q
What is subluxation?
A
Partial dislocation
12
Q
What is varus deformity?
A
Lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment osteoarthritis
13
Q
What is valgus deformity?
A
Lower limb deformity whereby whereby distal part is directed away from the midline e.g. hallux valgus
14
Q
What is gout?
A
- A disease in which tissue deposition of monosodium urate (MSU) crystals occurs as a result of hyperuricaemia and leads to gouty arthritis and/or tophi (aggregated deposits of MSU in tissue)
- Mainly caused by eating too much purine rich food (eg. red meats)
- Gouty arthritis commonly affects the metatarsophalangeal joint of the big toe (‘1st MTP joint’)
15
Q
List characteristics of gouty arthritis
A
- Abrupt onset
- Extremely painful
- Joint red, warm, swollen and tender
- Resolves spontaneously over 3-10 days (use of anti-inflammatory drugs to help improve symptoms)
16
Q
List the different areas of joint swelling and disease indicated
A
- Articular soft tissue involving joint synovium or effusion indicative of inflammatory joint disease
- Periarticular soft tissue involving the subcutaneous tissue indicative of inflammatory joint disease
- Non-articular synovial swelling involving bursa/ tendon sheath indicating inflammation of structure
- Bony areas indicating osteoarthritis
17
Q
What is enthesopathy?
A
- Pathology of the entesis (site where ligament or tendon inserts into bone)
- Eg. plantar fascitis and achilles tendinitis
18
Q
List the signs of irreversible joint damage
A
- Joint deformity (malalignment)
- Cepitus (audible and palpable sensation resulting from movement of one roughened surface on another. Classic features of osteoarthritis)
- Loss of joint range or abnormal movement
19
Q
What is affected by ankylosing spondylitis?
A
- Sacroiliac joints (sacroiliitis) and spine
- May lead to spinal fusion (ankylosis) and deformity
- Entheses resulting in chronic enthesopathy
- Non-axial joints – hips and shoulders (common), others less frequently involved
20
Q
List the signs of mechanical defects
A
- Painful restriction of motion in absence of features of inflammation (egl. knee locking)
- Instability (side to side movement of tibia on femur due to rupture of collateral knee ligmaments)
21
Q
List the causes of mechanical defects
A
- Inflammation
- Degenerative arthritis
- Trauma
22
Q
How is pattern of arthritis used in diangosis?
A
- Poly more than 4, oligo 2-4 and mono 1
- Symmetrical
- Size
- Axial involvement
- Bilateral and symmetrical invovment of large and small joints = rheumatoid arthritis
- Lower limb asymmetrical oligoarthritis and axial movement = reactive arthritis
- Exclusive inflammation of first metatarsophalangial joints = gout
23
Q
Describe synovial fluid production
A
- Hylauronic acid produced by type B cells in the synovium
- This thickens the fluid
- Abnormal increase is synovial effusion - due to abnormal mechanical stimulation eg. in osteoarthritis with damage to cartilage and bone (increase production, the excess production increases oncotic pressure and synovial volume)
24
Q
When is it useful to examine synovial fluid?
A
- Mandatory when infection suspected
- Useful to confirm diagnosis of crystal arthritis
- In inflammation there is inflammatory exudate - abnormal composition, inflammatory cells and mediators with reduced hyaluronic acid
25
How is synovial fluid examined?
Needle aspiration - at the bedside or using ultrasound guidance
26
List contraindications of arthrocentesis
- Conditions / disorders that increase risk of bleeding into joint during/after procedure
e. g. Anticoagulant drugs e.g. warfarin, low platelet counts, bleeding disorders like haemophilia
- Overlying skin infection because of risk of introducing infection into joint
27
What are possible complications of synovial fluid examination?
- Risk of introducing infection
- Bleeding into joint
- Damage to structures within the joint
28
What is raynauds phenomenon?
- Intermittent vasospasm of digits on exposure to cold
- Typical colour changes – white to blue to red
- Vasospasm leads to blanching of digit
- Cyanosis as static venous blood deoxygenates
- Reactive hyperaemia
- Raynaud’s phenomenon is most commonly isolated and benign condition (‘Primary Raynaud’s phenomenon’)
29
List characteristics of sjogrens syndrome
- Autoimmune exocrinopathy with lymphocytic infiltration of especially exocrine glands and sometimes of other organs (extra-glandular involvement)
- Typically diagnosed in middle-aged female (F:M = 9:1)
- Exocrine gland pathology results in
- Dry eyes (xerophthalmia)
- Dry mouth (xerostomia)
- Parotid gland enlargement
- Commonest extra-glandular manifestations are non-erosive arthritis and Raynaud’s phenomenon
30
What is secondary Sjorens syndrome?
In context of another connective tissue disorder
31
Which autoantibodies os sjogrens syndrome associated with?
- Antinuclear antibody (anti-ro and anti-la)
| - Rheumatoid factor
32
List the key points of inflammatory muscle disease
- Proximal muscle weakness due to autoimmune-mediated inflammation either with (dermatomyositis) or without (polymyositis) a rash
- Skin changes in dermatomyositis:
- Lilac-coloured (heliotrope) rash on eyelids, malar region and naso-labial folds
- 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)
33
List autoantibodies in inflammatory muscle disease
Antinuclear antibody – Anti-tRNA synthetase antibodies (e.g. anti-Jo-1 = histidyl)
34
List signs of inflammatory muscle disease
Elevated CPK, abnormal electromyograpghy, abnormal muscle biopsy (polymyositis = CD8 T cells; dermatomyositis = CD4 T cells in addition to B cells)
35
What is inflammatory muscle disease associated with?
- Malignancy (10-15%)
| - Pulmonary fibrosis)
36
List symptoms of systemic sclerosis
- Thickened skin with Raynaud’s phenomenon
- Dermal fibrosis, cutaneous calcinosis and telangiectasia
- Skin changes may be limited or diffuse
37
List symptoms of diffuse systemic sclerosis, and antibodies involved
- 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
38
List symptoms of limited systemic sclerosis and antibodies involved
- Fibrotic skin hands, forearms, feet, neck and face
- Anti-centromere antibodies
- Pulmonary hypertension
- Long history of Raynaud’s phenomenon
39
What is overlap syndrome?
- When features of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease we can use the term overlap syndrome
- When incomplete features of a connective tissue disease are present we can use the term undifferentiated connective tissue disease
40
List the factors of a locomotor examination
- Are any joints abnormal?
- What is the nature of the abnormality?
- What is the extent (distribution) of joint involvement? RA is very symmetrical
- Are there any other features of diagnostic importance present? (eg. butterfly rash in lupus)
41
List the three key questions in Gals
- Have you any pain or stiffness in your muscles, joints or back?
- Can you dress yourself completely without any difficulty?
- Can you walk up and down stairs without any difficulty?
42
List joints commonly spared in rheumatoid arthritis
- DIP
- Thoracic spine
- Lumbar spine
43
List joints spared in osteoarthritis
- MCP
- Wrist
- Elbow
- Shoulder
- Ankle
- Tarsal joints
44
List joints commonly involved in gout
- 1st MTP
- Ankle
- Knee
45
Describe the examination of synovial fluid
- Rapid gram stain followed by culture and antibiotic sensitivity assays
- Polarising light microscopy to detect crystals, which can be seen in arthritis due to gout or pseudogout
46
When are connective tissue disorders suspected?
- Arthralgia and arthritis is typically non-erosive
- Serum autoantibodies are characteristic and may aid diagnosis, correlate with disease activity, and may be directly pathogenic
- Raynaud’s phenomenon is common in these conditions
