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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
Q

what is indicative of inflammation of structure in relation to site of swelling and tissue involved

A

non-articular synovial involving bursa/tendon sheath

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26
Q

what is indicative of osteoarthritis in relation to site of swelling and tissue involved

A

bony areas involving articular ends of bone

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27
Q

define enthesopathy

A

pathology at enthesis (site where ligament/tendon inserts into bone)

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28
Q

2 examples of enthesopathy

A

plantar fascilitis, Achilles tendinitis

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29
Q

3 signs of irreversible joint damage in GALS screen

A

joint deformity, crepitus, loss of joint range/abnormal movement

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30
Q

joints affected in ankylosing spondylitis

A

sacroiliac joints, spine, non-axial joints (hip and shoulders common)

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31
Q

what does enthesis in ankylosing spondylitis result in

A

chronic enthesopathy

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32
Q

signs of mechanical defect in GALS screen

A

may be due to inflammation, degenrative arthritis or trauma so identified by painful restriction of motion in absence of features of inflammation, or instability

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33
Q

4 steps of determining pattern of arthritis

A

number of joints involved, if involvement is symmetrical, size of involved joints, determine if axial (spinal) involvement

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34
Q

poly- vs oligo- vs mono-arthritis

A

poly- affects > 4 joints, oligo- affects 2-4 joints, mono- affects single joint

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35
Q

what pattern is typical of rheumatoid arthritis

A

bilateral and symmetrical involvement of large and small joints

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36
Q

what pattern is typical of reactive arthritis

A

lower limb asymmetrical oligoarthritis and axial involvement

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37
Q

what pattern is typical of gout

A

exclusive inflammation of the first metatarsophalangeal joints without infection

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38
Q

joints commonly involved in rheumatoid arthritis

A

proximal interphalangeal joint, metacarpophalangeal joint, wrist, elbow, shoulder, cervical spine, hip, knee, ankle, tarsal, metatarsophalangeal joint

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39
Q

joints commonly spared in rheumatoid arthritis (focus on these as if involved, can discount disease)

A

distal interphalangeal joint, thoracic spine, lumbar spine

40
Q

joints commonly involved in osteoarthritis

A

1st carpometacarpal joint, distal interphalangeal joint, proximal interphalangeal joint, cervical spine, thoracolumbar spine, hip, knee, 1st metatarsophalangeal joint, toe interphalangeal joint

41
Q

joints commonly spared in osteoarthritis (focus on these as if involved, can discount disease)

A

metacarpophalangeal joint, wrist, elbow, shoulder, ankle, tarsal

42
Q

joints commonly involved in polyarticular gout

A

1st metacarpophalangeal joint, ankle, knee

43
Q

joints commonly spared in polyarticular gout (focus on these as if involved, can discount disease)

A

axial

44
Q

additional diagnostic features of rheumatoid arthritis

A

subcutaneous nodules (rheumatoid factor causing inflammation outside joint)

45
Q

additional diagnostic features of gout

A

tophi (subcutaneous deposits of uric acid)

46
Q

additional diagnostic features of systemic lupus erythematosus

A

malar rash

47
Q

what is synovial fluid (mainly determine if infection): everything after this card in the deck are optional with minimal assessment, but clinically useful

A

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
Q

what synthesise synovial fluid

A

type A (macrophage-like) and type B (fibroblast-like) synovial lining cells (type 1 collagen and proteoglycans)

49
Q

what do type B synovial lining cells secrete, and significance

A

hyaluronic acid, which results in increased viscosity of synovial fluid

50
Q

what is synovial effusion

A

abnormal increase in synovial fluid volume, which accumulates in joint disease

51
Q

cause of synovial effusion with normal composition

A

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
Q

cause of synovial effusion with abnormal composition

A

in synovitis due to inflammation, effusion is inflammatory exudate (abnormal composition), with inflamatory cells and mediators and reduces hyaluronic acid

53
Q

causes of non-inflammatory synovial effusions (slightly turbid)

A

osteoarthritis, mechanical defects

54
Q

causes of inflammatory synovial effusions (turbid)

A

gout, rheumatoid arthritis

55
Q

causes of infection synovial effusions (very turbid)

A

bacterial infections

56
Q

when is it mandatory to examine synovial fluid

A

when joint infection suspected

57
Q

when it is useful to examine synovial fluid

A

to confirm diagnosis in suspected crystal arthritis

58
Q

how is synovial fluid examination performed

A

needle aspiration under aseptic conditions (arthrocentesis)

59
Q

2 relative contraindications of arthrocentesis

A

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
Q

3 possible rare complications of arthrocentesis

A

introducing infection, bleeding into joint, damage to structures within joint

61
Q

what are synovial fluid samples routinely examined for

A

pathogens, crystals

62
Q

describe process of synovial fluid sample examination

A

rapid gram stain -> culture -> antibiotic sensitive assays -> polarising light microscopy to detect crystals (seen in arthritis due to gout or pseudogout)

63
Q

gout vs pseudogout: crystal

A

urate vs CPPD

64
Q

gout vs pseudogout: shape of crystal

A

needle vs brick-shaped

65
Q

gout vs pseudogout: polarising light microscopy (birefringence)

A

negative vs positive

66
Q

septic arthritis presentation in knee

A

acute pain, swelling of joint

67
Q

septic arthritis aspirated fluid

A

pus

68
Q

septic arthritis graim stain, culture and crystals

A

positive gram stain (cocci), culture e.g. S. aureus, crystals negative

69
Q

2 managements of septic arthritis

A

antibiotic therapy, lavage (washing)

70
Q

3 susceptibility factors for septic arthritis

A

impaired host defence (age, chronic illness, immunosuppressants), direct penetration, joint damage (prosthetic joint, chronic arthritis)

71
Q

sterile olecranon bursitis due to gout presentation

A

swelling behind elbow

72
Q

sterile olecranon bursitis due to gout aspirated fluid

A

bursal fluid

73
Q

sterile olecranon bursitis due to gout gram stain, culture and crystals

A

negative, negative, with crystals present which are needle-shaped and negatively birefringent

74
Q

3 key features of connective tissue disorders for early diagnosis

A

arthralgia and arthritis are typically non-erosive, serum autoantibodies are characteristic, Raynaud’s phenomenon is common

75
Q

3 features of characteristic serum autoantibodies in connective tissue disorders

A

may aid diagnosis, correlate with disease activity, may be directly pathogenic

76
Q

describe Raynaud’s phenomenon

A

intermittent vasospasm of digits on exposure to cold; most commonly isolated and benign

77
Q

colour change of digits in Raynaud’s phenomenon and why

A

white (vasospasm leads to blanching of digit) -> blue (cyanosis as static venous blood deoxygenates) -> red (reactive hyperaemia)

78
Q

presentation and clinical manifestations of systemic lupus erythematosus

A

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
Q

what is Sjögren’s syndrome

A

autoimmune exocrinopathy, with lymphocytic inflitration of especially exocrine glands and sometimes other organs (extra-glandular involvement)

80
Q

typical Sjögren’s syndrome patient

A

middle-aged female

81
Q

3 results of exocrine gland pathology in Sjögren’s syndrome

A

dry eyes, dry mouth, parotid gland involvement

82
Q

2 commonest extra-glandular involvements in Sjögren’s syndrome

A

non-erosive arthritis, Raynaud’s phenomenon

83
Q

what is secondary Sjögren’s syndrome

A

if occurs in context of another connective tissue disorder

84
Q

2 autoantibodies Sjögren’s syndrome associated with

A

antinuclear antibody, rheumatoid factor

85
Q

what is inflammatory muscle disease

A

proximal muscle weakness due to autoimmune-mediated inflammation either with a rash (dermatomyositis) or without a rash (polymiositis)

86
Q

4 skin changes in dermatomyositis

A

lilac-coloured rash on eyelids, malar region and naso-labial folds, red/purple flat/raised lesions on knuckles, subcutaneous calcinosis, mechanic’s hands

87
Q

autoantibodies associated with inflammatory muscle disease

A

antinuclear antibodies

88
Q

investigations of inflammatory muscle disease

A

elevated creatine phosphokinase, abnormal electromyography, abnormal muscle biopsy (CD8 T cells in polymiositis, CD4 T cells and B cells in dermatomyositis)

89
Q

what is inflammatory muscle disease associated with

A

malignancy (10-15%) and pulmonary fibrosis

90
Q

what is systemic sclerosis

A

thickened skin with Raynaud’s phenomenon (skin changes may be limited or diffuse)

91
Q

3 features of thickened skin in systemic sclerosis

A

dermal fibrosis, cutaneous calcinosis, telangiectasia

92
Q

4 features of diffuse systemic sclerosis

A

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
Q

4 features of limited systemic sclerosis

A

fibrotic skin hands, forearms, feet, neck and face; anti-centromere antibodies; pulmonary hypertension; long history of Raynaud’s phenomenon

94
Q

what is overlap syndrome

A

when features of more than 1 connective tissue disorder are present

95
Q

what is undifferentiated connective tissue disease

A

when incomplete features of a connective tissue disease are present

96
Q

what is mixed connective tissue disease

A

features of all and presence of anti-U1-RNP antibody

Y2 LCRS Musculoskeletal (18 decks)

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