The GALS Screen Flashcards
Define the following terms:
a. Arthritis
b. Arthralgia
c. Subluxation
d. Synovitis
e. Dislocation
a. Arthritis
Refers to definite inflammation of a joint
b. Arthralgia
Refers to pain within a joint without demonstrable inflammation by physical examination
c. Subluxation
Partial dislocation of a joint
d. Synovitis
Inflammation of the synovium
e. Dislocation
Articulating surfaces are displaced and are no longer in contact
What does GALS stand for?
Gait
Arms
Legs
Spine
What is gout caused by?
It is caused by deposition of monosodium urate (MSU) crystals as a result of hyperuricaemia
What are the key clinical features of gout?
Tophi – subcutaneous depositions of aggregated monosodium urate crystals
Gouty arthritis
Which joint is commonly affected by gouty arthritis?
1st Metatarsophalangeal joint – this is called podagra
List some signs of irreversible joint damage.
Joint deformity
Crepitus
Loss of joint range or abnormal movement
List some signs of a mechanical defect in the joint.
Painful restriction of movement in the absence of features of inflammation
Instability
How many joints have to be involved for arthritis to be classified as ‘monoarthritis’ ‘oligoarthritis’ and ‘polyarthritis’?
polyarthritis > 4 joints involved
oligoarthritis 2-4 joints involved
monoarthritis single affected joint
Describe the pattern of arthritis in the following diseases including the joints that are commonly affected and spared:
a. Rheumatoid arthritis
b. Reactive arthritis
c. Gout
a. Rheumatoid arthritis
Symmetrical polyarthritis involving large and small joints
Joints spared: DIP, lumbar spine, thoracic spine
Joints involved: most others
b. Reactive arthritis
Lower limb asymmetrical oligoarthritis and axial involvement
c. Gout
Exclusive inflammation of the 1st metatarsophalangeal joint
Joints commonly spared: axial
What is the main extra-articular feature of gout?
Tophi – subcutaneous deposits of uric acid
What are the two types of synovial lining cell?
Typa A – macrophage-like
Type B – fibroblast-like (secrete hyaluronic acid)
What is a synovial effusion?
Abnormal increase in synovial fluid volume
State two causes of spinal effusion and describe the synovial fluid composition in each of them.
Abnormal mechanical stimulation – can stimulate the fibroblasts to produce more hyaluronic acid – normal composition
Inflammation – inflammatory exudate – abnormal composition with inflammatory mediators and reduced hyaluronic acid
What features of the synovial fluid are examined to determine the cause of the synovial effusion?
How turbid it is
The presence and quantity of inflammatory cells (neutrophils in particular)
Non-inflammatory – slightly turbid – osteoarthritis or mechanical defects
Inflammatory – turbid – reactive arthritis or gout
Infection – very turbid – bacterial infection
When is synovial fluid examination performed?
When joint infection is suspected
Useful for confirming diagnosis of crystal arthritis
What are some contraindications for arthrocentesis?
Conditions that increase bleeding e.g. coagulopathy or anti-coagulant drugs
Overlying skin infection
List some possible complications of arthrocentesis
Risk of introducing infection
Bleeding into the joint
Damage to structures of the joint
What technique is used to detect crystals in the synovial fluid?
Polarising light microscopy
How is gout distinguished from pseudogout in synovial fluid examination?
Gout Urate crystals Needle shaped Negative birefringence (polarising light microscopy) Pseudogout Calcium pyrophosphate dehydrate (CPPD) crystals Brick shaped Positive birefringence
What is a common feature of most connective tissue diseases?
Raynaud’s phenomenon (intermittent vasospasm of the digits on exposure to the cold)
What is Sjogren’s syndrome and what are its symptoms?
Autoimmune exocrinopathy Symptoms: Dry eyes (xerophthalmia) Dry mouth (xerostomia) Parotid gland enlargement Extra-glandular features: non-erosive arthritis + Raynaud’s
Which antibodies are associated with Sjogren’s syndrome?
ANA
Anti-Ro
Anti-La
Rheumatoid factor
What is inflammatory muscle disease and what are the two types?
Proximal muscle weakness due to autoimmune-mediated inflammation either with a rash (dermatomyositis) or without a rash (polymyositis)
Describe the skin changes that take place in dermatomyositis.
Lilac rash on eyelid, malar region and naso-labial folds
Red or purple lesions on knuckles (Gottron’s papules)
Subcutaneous calcinosis
Mechanic’s hands (fissuring and cracking of the skin over the finger pads)
Which antibodies are associated with inflammatory muscle disease?
ANA
Anti-tRNA transferase antibodies
NOTE: also associated with elevated creatine phosphokinase, abnormal EMG and abnormal muscle biopsy
What other diseases is inflammatory muscle disease associated with?
Pulmonary fibrosis and Malignancy
What is systemic sclerosis?
Thickened skin with Raynaud’s phenomenon Features include:
Dermal fibrosis
Cutaneous calcinosis
Telangiectasia
What are the two types of systemic sclerosis and what are the differences between them?
Diffused systemic sclerosis
Fibrotic skin proximal to elbows or knees
Anti-Scl-70 antibodies
Pulmonary fibrosis and renal involvement
SHORT history of Raynaud’s
Limited systemic sclerosis
Fibrotic skin on hands, forearms, feet, neck and face
Anti-centromere antibodies
Pulmonary hypertension
LONG history of Raynaud’s
What is overlap syndrome?
When feature of more than one connective tissue disease are presen
What are the signs of active inflammation?
swelling (tumor)
warmth (calor)
erythema (rubor)
tenderness (dolor)
loss of function (functio laesa)
What are the aims of the locomotor examination?
- Are any of the joints abnormal?
- What is the nature of the joint abnormality?
- What is the extent (distribution) of the joint involvement?
- Are any other features of diagnostic importance present?
What are the components of the locomotor examination?
GALS
Detailed examination of abnormal joints
What is the detailed examination of abnormal joints comprised of?
inspection:
swelling, redness, deformity
palpation:
warmth, crepitus,
tenderness:
movement
active, passive, against resistance
function:
loss of function
Define enthesopathy
pathology at the enthesis i.e. the site where ligament or tendon inserts into bone
Give examples of 2 types of enthesopathy
plantar fasciitis
Achilles tendinitis
Define dislocation
articulating surfaces are displaced and no longer incontact
Define subluxation
partial dislocation
Define valgus
lower limb deformity whereby distal part is directed away from the midline e.g. hallux valgus
Define varus
lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment OA
What are the names for the hand deformities seen in rheumatoid arthritis?
Swan-neck and Boutonnière deformities
What are the names for the hand deformities seen in rheumatoid arthritis?
Swan-neck and Boutonnière deformities
What are the features of ankylosing spondulitis?
Chronic inflammatory disease affecting:
Sacroiliac joints (sacroiliitis) and spine - leads to spinal fusion (ankylosis) and deformity
Enthesopathy
Non-axial joints – hips and shoulders (common), others less frequently involved
What is ankylosing spondylitis associated with?
Strong association with HLA-B27
Rheumatoid factor is negative
