The GALS Screen

Question 1

What are the 3 main questions explored when investigating an abnormal joint

Answer 1

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?

Question 2

What is looked for in examination of the legs

Answer 2

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

Question 3

What kind of things are you looking for in inspection, palpation, movement and function during GALS

Answer 3

Inspection - swelling, redness, deformity
Palpation - warmth, crepitus, tenderness
Movement - Active, passive, against resistance
function - Loss of function

Question 4

What questions are asked to determine nature of joint abnormality

Answer 4

Is there inflammation?
Is there irreversible joint damage?
Is there a mechanical defect?

Question 5

What is gout

Answer 5

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)

Question 6

What joint does gout commonly affect

Answer 6

metatarsophalangeal joint of the big toe (‘1st MTP joint’)

Question 7

Describe the clinical features of gout

Answer 7

Abrupt onset
Extremely painful
Joint red, warm, swollen and tender
Resolves spontaneously over 3-10 days

Question 8

What are some signs of irreversible joint damage

Answer 8

Joint deformity
Crepitus
Loss of joint range or abnormal movement

Question 9

What are some signs of a mechanical defect in the joints

Answer 9

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

Question 10

What are the names given to arthritis of different numbers of joints

Answer 10

polyarthritis - > 4 joints involved
oligoarthritis - 2-4 joints involved
monoarthritis - single affected joint

Question 11

Describe the pattern of arthritis in rheumatoid arthritis, including the joints that are commonly affected and spared

Answer 11

Symmetrical polyarthritis involving large and small joints

Joints spared: DIP, lumbar spine, thoracic spine
Joints involved: most others

Question 12

Which joints are commonly affected in arthritis

Answer 12

Lower limb asymmetrical oligoarthritis and axial involvement

Question 13

Which joints are commonly affected and spared in gout

Answer 13

Exclusive inflammation of the 1st metatarsophalangeal joint

Joints commonly spared: axial

Question 14

What are some other features of musculoskeletal diseases that might be of diagnostic importance

Answer 14

Subcutaneous nodules - rheumatoid arthritis

Tophi - Gout

Malar rash - lupus

Question 15

What is synovial fluid and describe its appearance

Answer 15

Viscous fluid present in joint space of synovial joints (diarthroses)

Colourless or pale yellow transparent viscous film covering synovium and cartilage with few cells

Question 16

What does synovium contain

Answer 16

lining cells 1-3 cells deep in a matrix mainly containing type I collagen and proteoglycans

Question 17

What are the types of synovial lining cells

Answer 17

type A = macrophage-like

type B = fibroblast-like
Cells secrete the hyaluronic acid which results in the increased viscosity of synovial fluid

Question 18

What is a synovial effusion

Answer 18

Abnormal increase in synovial fluid volume

Question 19

What might cause a synovial effusion

Answer 19

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

Question 20

Describe the synovial fluid in synovitis due to inflammation

Answer 20

effusion is inflammatory exudate – abnormal composition: inflammatory cells and mediators, reduced hyaluronic acid

Question 21

How is synovial fluid examination carried out

Answer 21

needle aspiration under aseptic conditions (termed arthrocentesis)

Question 22

When is synovial fluid examination performed?

Answer 22

When joint infection is suspected

Suspected crystal arthritis

Question 23

Give some possible complications of arthrocentesis

Answer 23

Risk of introducing infection (i.e. creating a septic arthritis)
Bleeding into joint (haemarthrosis)
Damage to structures within the joint e.g. cartilage

Question 24

What are some contraindications for arthrocentesis?

Answer 24

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

Overlying skin infection

Question 25

What technique is used to examine synovial fluid for crystals

Answer 25

Polarising light microscopy to detect crystals which can be seen in arthritis due to gout or pseudogut

Question 26

What technique is used to examine synovial fluid for pathogens

Answer 26

Rapid Gram stain followed by culture and antibiotic sensitivity assays

Question 27

How is gout distinguished from pseudo gout

Answer 27

Gout - urate Crystal, needle shape, -ve light microscopy Psuedogout - CPPD, brick-shaped, +ve light microscopy

Question 28

Serum autoantibodies are characteristic and…

Answer 28

May aid diagnosis Correlate with disease activity May be directly pathogenic

Question 29

What it Raynaud's phenomenon

Answer 29

Intermittent vasospasm of digits on exposure to cold | Typical colour changes – white to blue to red

Question 30

What is Sjogrens syndrome

Answer 30

Autoimmune exocrinopathy | lymphocytic infiltration of especially exocrine glands and sometimes of other organs (extra-glandular involvement)

Question 31

What are the symptoms of Sjogrens syndrome

Answer 31

``` Dry eyes (xerophthalmia) Dry mouth (xerostomia) Parotid gland enlargement ```

Question 32

What are the most common extra-glandular manifestations Sjogrens syndrome

Answer 32

non-erosive arthritis and Raynaud’s phenomenon

Question 33

Which antibodies are associated with Sjogren’s syndrome?

Answer 33

Antinuclear antibody - Anti-Ro and Anti-La antibodies Rheumatoid factor

Question 34

What is inflammatory muscle disease

Answer 34

Autoimmune-mediated inflammation either with (dermatomyositis) or without (polymyositis) a rash Causes proximal muscle weakness

Question 35

Which antibodies are associated with inflammatory muscle diseases

Answer 35

Antinuclear antibody – Anti-tRNA synthetase antibodies

Question 36

What re the skin changes in dermatomyositis

Answer 36

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)

Question 37

What other diseases is inflammatory muscle disease associated with?

Answer 37

Malignancy | Pulmonary fibrosis

Question 38

What is systemic sclerosis

Answer 38

Thickened skin with Raynaud’s phenomenon | Dermal fibrosis, cutaneous calcinosis and telangiectasia

Question 39

What are the 2 types of systemic sclerosis

Answer 39

Diffuse systemic sclerosis | Limited systemic sclerosis

Question 40

Describe diffuse systemic sclerosis (which areas it affects, antibodies seen, other system involvement, Raynaud's phenomenon)

Answer 40

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

Question 41

Describe limited systemic sclerosis (which areas it affects, antibodies seen, other system involvement, Raynaud's phenomenon)

Answer 41

Fibrotic skin hands, forearms, feet, neck and face Anti-centromere antibodies Pulmonary hypertension Long history of Raynaud’s phenomenon

Question 42

What is overlap syndrome

Answer 42

When features of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease

Question 43

Define arthritis

Answer 43

refers to definite inflammation of a joint(s) i.e. swelling, tenderness and warmth of affected joints

Question 44

Define arthralgia

Answer 44

refers to pain within a joint(s) without demonstrable inflammation by physical examination

Question 45

Define dislocation

Answer 45

articulating surfaces are displaced and no longer in contact

Question 46

Define subluxation

Answer 46

Partial dislocation

Question 47

Define synovitis

Answer 47

Inflammation of the synovium