The GALS Screen Flashcards
Arthritis
Definite inflammation of a joint(s)
EG: swelling, tenderness and warmth of affected joints
Arthralgia
Pain within a joint without demonstrable inflammation by physical examination
Dislocation
Articulating surfaces are displaced and no longer in contact
Subluxation
Partial dislocation (some contact between articulating surfaces still remains)
Valgus deformity
Lower limb deformity whereby distal part is directed away from the midline (eg: hallux valgus)
Varus deformity
Lower limb deformity whereby distal part is directed towards the midline (eg: varus knee with medial compartment osteoarthritis)
GALS test
G=gait
A=arms
L=legs
S=spine
Gait
-Observe the patient walking, turning and walking back
LOOK FOR:
-smoothness and symmetry of leg, pelvis and arm movements
-normal stride length
-ability to turn quickly
Spine
- Press over mid-point of each supraspinatus and squeeze skinfold over trapezius (tenderness suggestive of fibromyalgia)
- From the side note the normal spine curvatures
- Ask patient to bend forward and touch their toes, with knees straight, to assess lumbar spine and hip flexion
- Try to place ear on the shoulder each side (tests lateral cervical flexion)
- observe from back of standing patient if paraspinal and shoulder girdle muscle bulk are symmetrical, if the spine is straight, if the iliac crests are level, if the gluteal muscle bulk is normal, if there are popliteal swellings and if the Achilles tendons are normal
Legs
- Observe any knee or foot deformity
- Assess flexion of hip and knee, whilst supporting the knee by passively internally rotating each hip in flexion
- Examine each knee for presence of fluid using ‘bulge’ sign and ‘patella tap’ sign
- Squeeze across metatarsals to detect any synovitis
- Inspect soles of feet for rashes and/or callosities
Signs of active inflammation
- Swelling (tumor)
- Warmth (calor)
- Erythema (rubor)
- Tenderness (dolor)
- Loss of function (functio laesa)
Joint deformity
Malalignment of two articulating bones
Crepitus
- Audible and palpable sensation resulting from movement of one roughened surface on another
- Classic feature of osteoarthritis (EG: patellofemoral crepitus on flexing the knee)
Ankylosing Spondylitis
Chronic inflammatory disease affecting:
- sacroiliac joints and spine (may lead to spinal fusion called ankylosis and joint deformity)
- entheses (resulting in chronic enthesopathy)
- non-axial joints (hips and shoulders common)
- strong HLA-B27 association
- negative rheumatoid factor
- sero-negative spondyloarthropathy
GALS examination key questions
- 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 the stairs without any difficulty?
Locomotor examination
DETAILED EXAMINATION OF ANY ABNORMAL JOINT IDENTIFIED IN GALS
- Inspection=swelling, redness, deformity?
- Palpation=warmth, crepitus, tenderness?
- Movement=active, passive, against resistance?
- Function=loss of function?
Gout
- acute gout=example of arthritis
- disease in which tissue deposition of monosodium urate crystals (MSU) occurs as result of hyperuricaemia and leads to one or more of: gouty arthritis and/or tophi
Gouty arthritis
- commonly affects 1st MTP joint (podagra)
- abrupt onset
- extremely painful
- joint=red, warm, swollen and tender=cardinal inflammation signs
- resolves spontaneously over 3-10 days
Tophi
Aggregated deposits of MSU in tissue
Articular soft tissue swelling
- involves joint synovium or effusion
- indicative of inflammatory joint disease
Periarticular soft tissue swelling
- involves subcutaneous tissue
- indicative of inflammatory joint disease
Non-articular synovial swelling
- involves bursa/tendon sheath
- indicative of inflammation of structure
Bony area swelling
- involves articular ends of bone
- indicative of osteoarthritis
Enthesopathy
-pathology at enthesis (site where ligament or tendon inserts into bone)
Examples include:
-achilles tendinitis
-plantar fasciitis
Signs of irreversible joint damage
- Joint deformity (malalignment of 2 articulating bones)
- Crepitus (audible and palpable sensation resulting from movement of 1 roughened surface on another=classic feature of osteoarthritis)
- Loss of joint range or abnormal movement
Signs of mechanical defect
May be due to inflammation, degenerative arthritis or trauma and identified by:
- painful restriction of motion in absence of inflammation features (eg: knee locking=due to meniscal tear or bone fragment)
- instability (eg: side-to-side movement of tibia on femur=due to ruptured collateral knee ligaments)
Polyarthritis
> 4 joints involved
Oligoarthritis
2-4 joints involved
Monoarthritis
Single affected joint
Arthritis pattern
-determine number of joints involved
-note if involvement is symmetrical
-note size of involved joints
-note any axial involvement
Examples include:
-bilateral and symmetrical involvement of large and small joints=rheumatoid arthritis
-lower limb asymmetrical oligoarthritis and axial movement=reactive arthritis
-exclusive inflammation of first metatarsophalangeal joint=gout
Other diagnostic features in locomotor examination
- Subcutaneous nodules=rheumatoid arthritis
- Tophi (subcutaneous deposits of MSU crystals=uric acid)
- Malar rash=SLE
Synovial fluid analysis////
- viscous fluid present in joint space of synovial joints (colourless or pale yellow, transparent, viscous=covers synovium and cartilage)
- synthesised by synovial lining cells (synovium is 1-3 lining cells deep in matrix mainly containing type I collagen and proteoglycans)
- Type A synovial lining cells=macrophage-like
- Type B synovial lining cells=fibroblast-like=secrete hyaluronic acid to increase synovial fluid viscosity
- synovial fluid rich in hyaluronic acid=can accumulate in joint disease (synovial effusion)
When is it important to examine synovial fluid?////
- mandatory when joint infection suspected
- useful to confirm diagnosis in suspected crystal arthritis
Synovial fluid examination procedure////
- needle aspiration under aseptic conditions (ARTHROCENTESIS)=collect synovial fluid from joint capsule
- don’t do aspiration for first metaphalangeal joint
Relative contraindications of arthrocentesis////
- conditions/disorders that increase bleeding risk into joint during/after procedure (eg: anticoagulant drug use, haemophilia etc)
- overlying skin infection because of risk of introducing infection into joint
Possible complications of arthrocentesis////
- risk of introducing infection (eg: creating septic arthritis)
- bleeding into joint (haemarthrosis)
- damage to structures within joint (cartilage)
SLE key points
- prototypic autoimmune disease
- typically females aged 15-45
- HLA-DR3 association
CLINICAL MANIFESTATION:
- hair loss
- mouth ulcers
- malar rash (erythema sparing nasolabial fold)
- photosensitive rash
- Raynaud’s phenomenon
- arthralgia and sometimes arthritis
- serositis
- renal disease
- cerebral disease
Sjogren’s syndrome key points
- autoimmune exocrinopathy (lymphocytic infiltration of exocrine glands and sometimes extra-glandular involvement)
- typically middle-aged females (F:M=9:1)
- exocrine gland pathology results in xerophthalmia (dry eyes), xerostomia (dry mouth) and parotid gland enlargement
- non-erosive arthritis and Raynaud’s phenomenon=commonest extra-glandular manifestation
- secondary Sjogren’s syndrome if occurs with another connective disorder
- autoantibody association=antinuclear antibody and rheumatoid factor
Inflammatory muscle disease key points
- proximal muscle weakness due to autoimmune-mediated inflammation either dermatomyositis or polymyositis (with or without rash)
- autoantibody association=antinuclear antibody
- elevated CPK (creatine phosphokinase), abnormal electromyography, abnormal muscle biopsy (CD8 T cells for polymyositis and CD4 T cells with B cells for dermatomyositis)
- malignancy and pulmonary fibrosis association
Systemic sclerosis key points
- thickened skin with Raynaud’s phenomenon=vasculopathy and skin problems(dermal fibrosis, cutaneous calcinosis and telangiectasia)
- diffuse or limited skin changes
Overlap syndrome key points
- when features of more than 1 connective tissue disorder are present
- when incomplete features of connective tissue disease are present=Undifferentiated connective tissue disease
- Mixed connective tissue disease=features of SLE, scleroderma, rheumatoid arthritis and polymyositis with anti-U1-RNP antibody presence common
Connective tissue disorders key points
EARLY DIAGNOSIS
- arthralgia and arthritis=typically non-erosive
- serum antibodies are characteristic=may aid diagnosis, correlate with disease activity and be directly pathogenic
- Raynaud’s phenomenon is common=intermittent digit vasospasm on exposure to cold (colour change from white->blue->red)
- colour change because: vasospasm leads to digit blanching, reactive hyperaemia and cyanosis as static venous blood deoxygenates
- Raynaud’s phenomenon=commonly isolated and benign condition
Nature of the joint abnormality
- any inflammation?
- irreversible joint damage?
- mechanical defect?
Synovial effusion
-abnormal increase in synovial fluid volume
Normal composition:
Abnormal mechanical stimulation will increase hyaluronic acid production by synovial fibroblasts= excess increases oncotic pressure which increases synovial volume
Abnormal composition:
-in synovitis due to inflammation, effusion is inflammatory exudate=inflammatory cells, inflammatory mediators and reduced hyaluronic acid
Normal synovial effusion
- clear/pale yellow and viscous appearance
- <10% neutrophils
Non-inflammatory synovial effusion
- slightly cloudy (turbid)
- causes: osteoarthritis and mechanical defects
- 10-20% neutrophils
Inflammatory synovial effusion
- cloudy (turbid)
- causes: gout and rheumatoid arthritis
- 20-70% neutrophils
Infection synovial effusion
- very cloudy (very turbid)
- causes: bacterial infections
- > 70% neutrophils
Synovial fluid tests
- rapid gram stain followed by culture and antibiotic sensitivity assays
- polarising light microscopy to detect crystals=arthritis due to gout or pseudogout
Gout analysis
- urate crystal
- needle-shaped crystal
- negative birefringence
Pseudogout analysis
- CPPD crystals (calcium pyrophosphate dihydrate)
- brick-shaped crystal
- positive birefringence
Dermatomyositis skin changes
- lilac coloured (heliotrope) rash on eyelids, malar region and nasolabial folds
- subcutaneous calcinosis
- Gottron’s papules=red/purple flat or raised lesions on knuckles
- Mechanic’s hands=fissuring and cracking of skin over finger pads
Diffuse systemic sclerosis
- fibrotic skin proximal to elbows or knees (excluding face and neck)
- anti-topoisomerase-1 antibodies
- pulmonary fibrosis and renal involvement
- short history of Raynaud’s phenomenon
Limited systemic sclerosis
- fibrotic skin hands, forearms, feet, neck and face
- anti-centromere antibodies
- pulmonary hypertension
- long history of Raynaud’s phenomenon
CREST
- subtype of limited systemic sclerosis
- Calcinosis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasia
