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Y2 LCRS Musculoskeletal > rheumatology and orthopaedics > Flashcards

rheumatology and orthopaedics Flashcards

GALS screen: recall and perform the GALS examination, and define arthritis, arthralgia, subluxation and synovitis

1
Q

what can the GALS score (screening test) rapidly determine (4) by looking for early signs

A

are any joints abnormal, nature of joint abnormality (inflammatory or mechanical), extent of joint involvement (number, symmetry), any other features of diagnostic importance present

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2
Q

what does GALS stand for

A

gait, arms, legs, spine

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3
Q

what are the 3 key questions of the GALS examination before examination

A

pain/stiffness in muscles, joints or back? - inflammation; dress yourself completely without difficulty?; walk up/down stairs without difficulty? - also thinking about neurological etc.

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4
Q

GALS: describe gait stage process

A

observe patient walking, turning and walking back

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5
Q

GALS: describe gait stage observations

A

smoothness and symmetry of leg, pelvis and arm movements; normal stride length; ability to turn quickly

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6
Q

GALS: describe spine stage observations (don’t need to know in huge detail)

A

is paraspinal and shoulder girdle muscle bulk symetrical, is spine straight, are iliac crests level, is gluteal muscle bulk normal, are there popliteal swellings, are Achilles tendons normal, signs of fibromyalgia, are spinal curvatures normal, is lumbar spine (ankylosing spondylitis loses lumbar curvature) and hip flexion normal, is lateral cervical spine movement normal

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7
Q

GALS: describe arm stage process and observations

A

look for normal girlde muscle bulk and symmetry, look to see if full extension at elbows, are shoulder joints normal, examine hands down with fingers straight, observe supination, pronation, grip and finger movements, squeeze test for synovitis at metacarpophalangeal joints

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8
Q

GALS: describe leg stage process and observations

A

look for knee or foot deformity, assess flexion of hip and knee, look for knee swellings, squeeze test for synovitis at metatarsophalangeal joints, inspect soles of feet

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9
Q

4 detailed examination methods of any abnormal joints identified in GALS screen (determine mechanical or inflammation)

A

inspection, palpation, movement, function (loss of function)

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10
Q

3 inspections of any abnormal joints identified in GALS screen

A

swelling, redness, deformity

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11
Q

3 palpations of any abnormal joints identified in GALS screen

A

warmth, cepitus, tenderness

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12
Q

3 movements of any abnormal joints identified in GALS screen

A

active, passive, against resistance

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13
Q

3 questions to determine nature of joint abnormality

A

is there inflammation, is there irreversible joint damage, is there mechanical defect

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14
Q

5 signs of inflammation

A

swelling (most useful), warmth, erythema, tenderness (most useful), loss of function

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15
Q

what does arthritis refer to

A

definite inflammation of a joint(s) i.e. swelling, tenderness and warmth of affected joints e.g. acute gout

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16
Q

what does arthralgia refer to

A

pain within a joint(s) without demonstrable inflammation by physical examination

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17
Q

what does dislocation refer to

A

articulating surfaces are displaced and no longer in contact

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18
Q

what does subluxation refer to

A

partial dislocation

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19
Q

what does varus deformity refer to

A

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

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20
Q

what does valgus deformity refer to

A

lower limb deformity whereby whereby distal part is directed away from the midline e.g. hallux valgus

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21
Q

define gout

A

crystal arthritis disease in which tissue deposition of monosodium urate (MSU) crystals occurs as a result of hyperuricaemia (e.g. diet) and leads to gouty arthritis and/or
tophi (aggregated deposits of MSU in tissue); must exclude infection (e.g. synovial fluid examination)

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22
Q

where does gouty arthritis commonly affect

A

metatarsophalangeal joint of big toe

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23
Q

4 characteristics of gouty arthritis

A

abrupt onset; extremely painful; red, warm, swollen and tender joint; resolves spontaneously in 3-10 days

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24
Q

what is indicative of inflammatory joint disease in relation to site of swelling and tissue involved

A

articular soft tissue involving joint synovium or effusion, or periarticular soft tissue involving subcutaneous tissue

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25
what is indicative of inflammation of structure in relation to site of swelling and tissue involved
non-articular synovial involving bursa/tendon sheath
26
what is indicative of osteoarthritis in relation to site of swelling and tissue involved
bony areas involving articular ends of bone
27
define enthesopathy
pathology at enthesis (site where ligament/tendon inserts into bone)
28
2 examples of enthesopathy
plantar fascilitis, Achilles tendinitis
29
3 signs of irreversible joint damage in GALS screen
joint deformity, crepitus, loss of joint range/abnormal movement
30
joints affected in ankylosing spondylitis
sacroiliac joints, spine, non-axial joints (hip and shoulders common)
31
what does enthesis in ankylosing spondylitis result in
chronic enthesopathy
32
signs of mechanical defect in GALS screen
may be due to inflammation, degenrative arthritis or trauma so identified by painful restriction of motion in absence of features of inflammation, or instability
33
4 steps of determining pattern of arthritis
number of joints involved, if involvement is symmetrical, size of involved joints, determine if axial (spinal) involvement
34
poly- vs oligo- vs mono-arthritis
poly- affects > 4 joints, oligo- affects 2-4 joints, mono- affects single joint
35
what pattern is typical of rheumatoid arthritis
bilateral and symmetrical involvement of large and small joints
36
what pattern is typical of reactive arthritis
lower limb asymmetrical oligoarthritis and axial involvement
37
what pattern is typical of gout
exclusive inflammation of the first metatarsophalangeal joints without infection
38
joints commonly involved in rheumatoid arthritis
proximal interphalangeal joint, metacarpophalangeal joint, wrist, elbow, shoulder, cervical spine, hip, knee, ankle, tarsal, metatarsophalangeal joint
39
joints commonly spared in rheumatoid arthritis (focus on these as if involved, can discount disease)
distal interphalangeal joint, thoracic spine, lumbar spine
40
joints commonly involved in osteoarthritis
1st carpometacarpal joint, distal interphalangeal joint, proximal interphalangeal joint, cervical spine, thoracolumbar spine, hip, knee, 1st metatarsophalangeal joint, toe interphalangeal joint
41
joints commonly spared in osteoarthritis (focus on these as if involved, can discount disease)
metacarpophalangeal joint, wrist, elbow, shoulder, ankle, tarsal
42
joints commonly involved in polyarticular gout
1st metacarpophalangeal joint, ankle, knee
43
joints commonly spared in polyarticular gout (focus on these as if involved, can discount disease)
axial
44
additional diagnostic features of rheumatoid arthritis
subcutaneous nodules (rheumatoid factor causing inflammation outside joint)
45
additional diagnostic features of gout
tophi (subcutaneous deposits of uric acid)
46
additional diagnostic features of systemic lupus erythematosus
malar rash
47
what is synovial fluid (mainly determine if infection): everything after this card in the deck are optional with minimal assessment, but clinically useful
colourless/pale yellow viscous fluid present in joint space of synovial joints (diarthroses), covering synovium and cartilage with few cells, which is rich in hyaluronic acid
48
what synthesise synovial fluid
type A (macrophage-like) and type B (fibroblast-like) synovial lining cells (type 1 collagen and proteoglycans)
49
what do type B synovial lining cells secrete, and significance
hyaluronic acid, which results in increased viscosity of synovial fluid
50
what is synovial effusion
abnormal increase in synovial fluid volume, which accumulates in joint disease
51
cause of synovial effusion with normal composition
abnormal mechanical stimulation (e.g. in osteoarthritis): increased production of hyaluronic aid by synovial fibroblasts due to mechanical forces -> increased oncotic pressure and synovial volume (normal composition)
52
cause of synovial effusion with abnormal composition
in synovitis due to inflammation, effusion is inflammatory exudate (abnormal composition), with inflamatory cells and mediators and reduces hyaluronic acid
53
causes of non-inflammatory synovial effusions (slightly turbid)
osteoarthritis, mechanical defects
54
causes of inflammatory synovial effusions (turbid)
gout, rheumatoid arthritis
55
causes of infection synovial effusions (very turbid)
bacterial infections
56
when is it mandatory to examine synovial fluid
when joint infection suspected
57
when it is useful to examine synovial fluid
to confirm diagnosis in suspected crystal arthritis
58
how is synovial fluid examination performed
needle aspiration under aseptic conditions (arthrocentesis)
59
2 relative contraindications of arthrocentesis
conditions/disorders that increase risk of bleeding into joint during/after procedure (e.g. anticoagulant drugs, low platelet counts, bleeding disorders like haemophilia), overlying skin infection (risk of introducing infection into joint)
60
3 possible rare complications of arthrocentesis
introducing infection, bleeding into joint, damage to structures within joint
61
what are synovial fluid samples routinely examined for
pathogens, crystals
62
describe process of synovial fluid sample examination
rapid gram stain -> culture -> antibiotic sensitive assays -> polarising light microscopy to detect crystals (seen in arthritis due to gout or pseudogout)
63
gout vs pseudogout: crystal
urate vs CPPD
64
gout vs pseudogout: shape of crystal
needle vs brick-shaped
65
gout vs pseudogout: polarising light microscopy (birefringence)
negative vs positive
66
septic arthritis presentation in knee
acute pain, swelling of joint
67
septic arthritis aspirated fluid
pus
68
septic arthritis graim stain, culture and crystals
positive gram stain (cocci), culture e.g. S. aureus, crystals negative
69
2 managements of septic arthritis
antibiotic therapy, lavage (washing)
70
3 susceptibility factors for septic arthritis
impaired host defence (age, chronic illness, immunosuppressants), direct penetration, joint damage (prosthetic joint, chronic arthritis)
71
sterile olecranon bursitis due to gout presentation
swelling behind elbow
72
sterile olecranon bursitis due to gout aspirated fluid
bursal fluid
73
sterile olecranon bursitis due to gout gram stain, culture and crystals
negative, negative, with crystals present which are needle-shaped and negatively birefringent
74
3 key features of connective tissue disorders for early diagnosis
arthralgia and arthritis are typically non-erosive, serum autoantibodies are characteristic, Raynaud's phenomenon is common
75
3 features of characteristic serum autoantibodies in connective tissue disorders
may aid diagnosis, correlate with disease activity, may be directly pathogenic
76
describe Raynaud's phenomenon
intermittent vasospasm of digits on exposure to cold; most commonly isolated and benign
77
colour change of digits in Raynaud's phenomenon and why
white (vasospasm leads to blanching of digit) -> blue (cyanosis as static venous blood deoxygenates) -> red (reactive hyperaemia)
78
presentation and clinical manifestations of systemic lupus erythematosus
typically female between 15-45, malar rash, photosensitive rash, mouth ulcers, hair loss, Raynaud's phenomenon, arthralgia (sometimes arthritis), serositis, renal disease, cerebral disease
79
what is Sjögren’s syndrome
autoimmune exocrinopathy, with lymphocytic inflitration of especially exocrine glands and sometimes other organs (extra-glandular involvement)
80
typical Sjögren’s syndrome patient
middle-aged female
81
3 results of exocrine gland pathology in Sjögren’s syndrome
dry eyes, dry mouth, parotid gland involvement
82
2 commonest extra-glandular involvements in Sjögren’s syndrome
non-erosive arthritis, Raynaud's phenomenon
83
what is secondary Sjögren’s syndrome
if occurs in context of another connective tissue disorder
84
2 autoantibodies Sjögren’s syndrome associated with
antinuclear antibody, rheumatoid factor
85
what is inflammatory muscle disease
proximal muscle weakness due to autoimmune-mediated inflammation either with a rash (dermatomyositis) or without a rash (polymiositis)
86
4 skin changes in dermatomyositis
lilac-coloured rash on eyelids, malar region and naso-labial folds, red/purple flat/raised lesions on knuckles, subcutaneous calcinosis, mechanic's hands
87
autoantibodies associated with inflammatory muscle disease
antinuclear antibodies
88
investigations of inflammatory muscle disease
elevated creatine phosphokinase, abnormal electromyography, abnormal muscle biopsy (CD8 T cells in polymiositis, CD4 T cells and B cells in dermatomyositis)
89
what is inflammatory muscle disease associated with
malignancy (10-15%) and pulmonary fibrosis
90
what is systemic sclerosis
thickened skin with Raynaud's phenomenon (skin changes may be limited or diffuse)
91
3 features of thickened skin in systemic sclerosis
dermal fibrosis, cutaneous calcinosis, telangiectasia
92
4 features of diffuse systemic sclerosis
fibrotic skin proximal to elbows or knees excluding face and neck, anti-topoisomerase-1 autoantibodies, pulmonary fibrosis and renal involvement, short history of Raynaud's phenomenon
93
4 features of limited systemic sclerosis
fibrotic skin hands, forearms, feet, neck and face; anti-centromere antibodies; pulmonary hypertension; long history of Raynaud's phenomenon
94
what is overlap syndrome
when features of more than 1 connective tissue disorder are present
95
what is undifferentiated connective tissue disease
when incomplete features of a connective tissue disease are present
96
what is mixed connective tissue disease
features of all and presence of anti-U1-RNP antibody

Y2 LCRS Musculoskeletal (18 decks)

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