Musculoskeletal 8 - The Gals Screen Flashcards
What is the gals examination?
- Screening test designed to be quick and determine if nay joints are abnormal
- Gait (observe patients walking, turning and walking back)
- Arms
- Legs
- Spine
What do you look for when assessing gait?
- Smoothness and symmetry of leg, pelvis and arm movements
- Normal stride length
- Ability to turn quickly
What do you look for in the spine?
- 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?
What do you look for in the arms?
- 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)
What is looked for in the legs?
- 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
How are abnormal joints examined?
- Inspection: swelling, redness, deformity
- Palpation: warmth, crepitus, tenderness
- Movement: active, passive, against resistance
- Function: loss of function
How is the nature of the joint abnormality assessed?
- Is there inflammation? (swelling, warmth, erythema, tenderness, loss of function)
- Is there irreversible joint damage?
- Is there a mechanical defect?
What is arthritis?
Definite inflammation of a joint(s) i.e. swelling, tenderness and warmth of affected joints
What is arthralgia?
Refers to pain within a joint(s) without demonstrable inflammation by physical examination - seen in lupus
What is dislocation?
Articulating surfaces are displaced and no longer in contact
What is subluxation?
Partial dislocation
What is varus deformity?
Lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment osteoarthritis
What is valgus deformity?
Lower limb deformity whereby whereby distal part is directed away from the midline e.g. hallux valgus
What is gout?
- 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’)
List characteristics of gouty arthritis
- 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)
List the different areas of joint swelling and disease indicated
- 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
What is enthesopathy?
- Pathology of the entesis (site where ligament or tendon inserts into bone)
- Eg. plantar fascitis and achilles tendinitis
List the signs of irreversible joint damage
- 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
What is affected by ankylosing spondylitis?
- 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
List the signs of mechanical defects
- 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)
List the causes of mechanical defects
- Inflammation
- Degenerative arthritis
- Trauma
How is pattern of arthritis used in diangosis?
- 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
Describe synovial fluid production
- 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)
When is it useful to examine synovial fluid?
- 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
How is synovial fluid examined?
Needle aspiration - at the bedside or using ultrasound guidance
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
What are possible complications of synovial fluid examination?
- Risk of introducing infection
- Bleeding into joint
- Damage to structures within the joint
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’)
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
What is secondary Sjorens syndrome?
In context of another connective tissue disorder
Which autoantibodies os sjogrens syndrome associated with?
- Antinuclear antibody (anti-ro and anti-la)
- Rheumatoid factor
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)
List autoantibodies in inflammatory muscle disease
Antinuclear antibody – Anti-tRNA synthetase antibodies (e.g. anti-Jo-1 = histidyl)
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)
What is inflammatory muscle disease associated with?
- Malignancy (10-15%)
- Pulmonary fibrosis)
List symptoms of systemic sclerosis
- Thickened skin with Raynaud’s phenomenon
- Dermal fibrosis, cutaneous calcinosis and telangiectasia
- Skin changes may be limited or diffuse
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
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
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
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)
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?
List joints commonly spared in rheumatoid arthritis
- DIP
- Thoracic spine
- Lumbar spine
List joints spared in osteoarthritis
- MCP
- Wrist
- Elbow
- Shoulder
- Ankle
- Tarsal joints
List joints commonly involved in gout
- 1st MTP
- Ankle
- Knee
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
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
