The GALS screen

Question 1

Define the following terms:

a. Arthritis
b. Arthralgia
c. Subluxation
d. Synovitis
e. Dislocation

Answer 1

Arthritis - Refers to definite inflammation of a joint

Arthralgia - Refers to pain within a joint without demonstrable inflammation by physical examination

Subluxation - Partial dislocation of a joint

Synovitis - Inflammation of the synovium

Dislocation - Articulating surfaces are displaced and are no longer in contact

Question 2

What does GALS stand for?

Answer 2

Gait
Arms
Legs
Spine

Question 3

What is gout caused by?

Answer 3

It is caused by deposition of monosodium urate (MSU) crystals as a result of hyperuricaemia

Question 4

What are the key clinical features of gout?

Answer 4

Tophi – subcutaneous depositions of aggregated monosodium urate crystals
Gouty arthritis

Question 5

Which joint is commonly affected by gouty arthritis?

Answer 5

1st Metatarsophalangeal joint – this is called podagra

Question 6

List some signs of irreversible joint damage

Answer 6

Joint deformity
Crepitus
Loss of joint range or abnormal movement

Question 7

List some signs of a mechanical defect in the joint.

Answer 7

Painful restriction of movement in the absence of features of inflammation
Instability

Question 8

How many joints have to be involved for arthritis to be classified as ‘oligoarthritis’?

Answer 8

2-4

Question 9

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

Answer 9

Rheumatoid arthritis - Symmetrical polyarthritis involving large and small joints
Joints spared: DIP, lumbar spine, thoracic spine
Joints involved: most others

Reactive arthritis - Lower limb asymmetrical oligoarthritis and axial involvement

Gout - Exclusive inflammation of the 1st metatarsophalangeal joint
Joints commonly spared: axial

Question 10

What is the main extra-articular feature of gout?

Answer 10

Tophi – subcutaneous deposits of uric acid

Question 11

What are the two types of synovial lining cell?

Answer 11

Type A – macrophage-like

Type B – fibroblast-like (secrete hyaluronic acid)

Question 12

What is a synovial effusion?

Answer 12

Abnormal increase in synovial fluid volume

Question 13

State two causes of spinal effusion and describe the synovial fluid composition in each of them.

Answer 13

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

Question 14

What features of the synovial fluid are examined to determine the cause of the synovial effusion?

Answer 14

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

Question 15

When is synovial fluid examination performed?

Answer 15

When joint infection is suspected

Useful for confirming diagnosis of crystal arthritis

Question 16

What are some contraindications for arthrocentesis?

Answer 16

Conditions that increase bleeding e.g. coagulopathy or anti-coagulant drugs
Overlying skin infection

Question 17

List some possible complications of arthrocentesis

Answer 17

Risk of introducing infection
Bleeding into the joint
Damage to structures of the joint

Question 18

What technique is used to detect crystals in the synovial fluid?

Answer 18

Polarising light microscopy

Question 19

How is gout distinguished from pseudogout in synovial fluid examination?

Answer 19

Gout
• Urate crystals
• Needle shaped
• Negative birefringence (polarising light microscopy)

Pseudogout
• Calcium pyrophosphate dehydrate (CPPD) crystals
• Brick shaped
• Positive birefringence

Question 20

What is a common feature of most connective tissue diseases?

Answer 20

Raynaud’s phenomenon (intermittent vasospasm of the digits on exposure to the cold)

Question 21

What is Sjogren’s syndrome and what are its symptoms?

Answer 21

Autoimmune exocrinopathy 
Symptoms: 
Dry eyes (xerophthalmia) 
Dry mouth (xerostomia) 
Parotid gland enlargement 
Extra-glandular features: non-erosive arthritis + Raynaud’s

Question 22

Which antibodies are associated with Sjogren’s syndrome?

Answer 22

ANA
Anti-Ro
Anti-La
Rheumatoid factor

Question 23

What is inflammatory muscle disease and what are the two types?

Answer 23

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

Question 24

Describe the skin changes that take place in dermatomyositis.

Answer 24

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)

Question 25

Which antibodies are associated with inflammatory muscle disease?

Answer 25

ANA
Anti-tRNA transferase antibodies
NOTE: also associated with elevated creatine phosphokinase, abnormal EMG and abnormal muscle biopsy

Question 26

What other diseases is inflammatory muscle disease associated with?

Answer 26

Pulmonary fibrosis and Malignancy

Question 27

What is systemic sclerosis?

Answer 27

Thickened skin with Raynaud’s phenomenon Features include:
• Dermal fibrosis
• Cutaneous calcinosis
• Telangiectasia

Question 28

What are the two types of systemic sclerosis and what are the differences between them?

Answer 28

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

Question 29

What is overlap syndrome?

Answer 29

When feature of more than one connective tissue disease are present