The GALS Screen Flashcards
What are the 3 main questions explored when investigating an abnormal joint
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 is looked for in examination of the legs
Look for knee or foot deformity Assess flexion of hip and knee Look for knee swellings Test for synovitis at the metatarso-phalangeal joints (MTP joints) Inspect soles of the feet
What kind of things are you looking for in inspection, palpation, movement and function during GALS
Inspection - swelling, redness, deformity Palpation - warmth, crepitus, tenderness Movement - Active, passive, against resistance function - Loss of function
What questions are asked to determine nature of joint abnormality
Is there inflammation?
Is there irreversible joint damage?
Is there a mechanical defect?
What is gout
Tissue deposition of monosodium urate (MSU) crystals as a result of hyperuricaemia and leads to one or more of the following:
Gouty arthritis
Tophi (aggregated deposits of MSU in tissue)
What joint does gout commonly affect
metatarsophalangeal joint of the big toe (‘1st MTP joint’)
Describe the clinical features of gout
Abrupt onset
Extremely painful
Joint red, warm, swollen and tender
Resolves spontaneously over 3-10 days
What are some signs of irreversible joint damage
Joint deformity
Crepitus
Loss of joint range or abnormal movement
What are some signs of a mechanical defect in the joints
painful restriction of motion in absence of features of inflammation
e.g. knee ‘locking’ due to meniscal tear or bone fragment
instability
e.g. side-to-side movement of tibia on femur due to ruptured collateral knee ligaments
What are the names given to arthritis of different numbers of joints
polyarthritis - > 4 joints involved
oligoarthritis - 2-4 joints involved
monoarthritis - single affected joint
Describe the pattern of arthritis in rheumatoid arthritis, including the joints that are commonly affected and spared
Symmetrical polyarthritis involving large and small joints
Joints spared: DIP, lumbar spine, thoracic spine
Joints involved: most others
Which joints are commonly affected in arthritis
Lower limb asymmetrical oligoarthritis and axial involvement
Which joints are commonly affected and spared in gout
Exclusive inflammation of the 1st metatarsophalangeal joint
Joints commonly spared: axial
What are some other features of musculoskeletal diseases that might be of diagnostic importance
Subcutaneous nodules - rheumatoid arthritis
Tophi - Gout
Malar rash - lupus
What is synovial fluid and describe its appearance
Viscous fluid present in joint space of synovial joints (diarthroses)
Colourless or pale yellow transparent viscous film covering synovium and cartilage with few cells
What does synovium contain
lining cells 1-3 cells deep in a matrix mainly containing type I collagen and proteoglycans
What are the types of synovial lining cells
type A = macrophage-like
type B = fibroblast-like
Cells secrete the hyaluronic acid which results in the increased viscosity of synovial fluid
What is a synovial effusion
Abnormal increase in synovial fluid volume
What might cause a synovial effusion
Abnormal mechanical stimulation
Increase production of hyaluronic acid by synovial fibroblasts due to mechanical forces
Excess hyaluronic acid increases oncotic pressure and increases synovial volume – normal composition
Describe the synovial fluid in synovitis due to inflammation
effusion is inflammatory exudate – abnormal composition: inflammatory cells and mediators, reduced hyaluronic acid
How is synovial fluid examination carried out
needle aspiration under aseptic conditions (termed arthrocentesis)
When is synovial fluid examination performed?
When joint infection is suspected
Suspected crystal arthritis
Give some possible complications of arthrocentesis
Risk of introducing infection (i.e. creating a septic arthritis)
Bleeding into joint (haemarthrosis)
Damage to structures within the joint e.g. cartilage
What are some contraindications for arthrocentesis?
Conditions that increase bleeding e.g. coagulopathy or anti-coagulant drugs
Overlying skin infection
What technique is used to examine synovial fluid for crystals
Polarising light microscopy to detect crystals which can be seen in arthritis due to gout or pseudogut
What technique is used to examine synovial fluid for pathogens
Rapid Gram stain followed by culture and antibiotic sensitivity assays
How is gout distinguished from pseudo gout
Gout - urate Crystal, needle shape, -ve light microscopy
Psuedogout - CPPD, brick-shaped, +ve light microscopy
Serum autoantibodies are characteristic and…
May aid diagnosis
Correlate with disease activity
May be directly pathogenic
What it Raynaud’s phenomenon
Intermittent vasospasm of digits on exposure to cold
Typical colour changes – white to blue to red
What is Sjogrens syndrome
Autoimmune exocrinopathy
lymphocytic infiltration of especially exocrine glands and sometimes of other organs (extra-glandular involvement)
What are the symptoms of Sjogrens syndrome
Dry eyes (xerophthalmia) Dry mouth (xerostomia) Parotid gland enlargement
What are the most common extra-glandular manifestations Sjogrens syndrome
non-erosive arthritis and Raynaud’s phenomenon
Which antibodies are associated with Sjogren’s syndrome?
Antinuclear antibody - Anti-Ro and Anti-La antibodies
Rheumatoid factor
What is inflammatory muscle disease
Autoimmune-mediated inflammation either with (dermatomyositis) or without (polymyositis) a rash
Causes proximal muscle weakness
Which antibodies are associated with inflammatory muscle diseases
Antinuclear antibody – Anti-tRNA synthetase antibodies
What re the skin changes in dermatomyositis
Lilac-coloured (heliotrope) rash on eyelids, malar region and naso-labial folds
Red or purple flat or raised lesions on knuckles (Gottron’s papules)
Subcutaneous calcinosis
Mechanic’s hands (fissuring and cracking of skin over finger pads)
What other diseases is inflammatory muscle disease associated with?
Malignancy
Pulmonary fibrosis
What is systemic sclerosis
Thickened skin with Raynaud’s phenomenon
Dermal fibrosis, cutaneous calcinosis and telangiectasia
What are the 2 types of systemic sclerosis
Diffuse systemic sclerosis
Limited systemic sclerosis
Describe diffuse systemic sclerosis (which areas it affects, antibodies seen, other system involvement, Raynaud’s phenomenon)
Fibrotic skin proximal to elbows or knees (excluding face and neck)
Anti-topoisomerase-1 antibodies
Pulmonary fibrosis, renal involvement
Short history of Raynaud’s phenomenon
Describe limited systemic sclerosis (which areas it affects, antibodies seen, other system involvement, Raynaud’s phenomenon)
Fibrotic skin hands, forearms, feet, neck and face
Anti-centromere antibodies
Pulmonary hypertension
Long history of Raynaud’s phenomenon
What is overlap syndrome
When features of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease
Define arthritis
refers to definite inflammation of a joint(s) i.e. swelling, tenderness and warmth of affected joints
Define arthralgia
refers to pain within a joint(s) without demonstrable inflammation by physical examination
Define dislocation
articulating surfaces are displaced and no longer in contact
Define subluxation
Partial dislocation
Define synovitis
Inflammation of the synovium
