Updated: 12/11/2018

Psoriatic Arthritis

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https://upload.orthobullets.com/topic/9050/images/psa4-50[1]_moved.jpg
https://upload.orthobullets.com/topic/9050/images/skinrash.jpg
https://upload.orthobullets.com/topic/9050/images/dactylitis.jpg
https://upload.orthobullets.com/topic/9050/images/img_0245.jpg
https://upload.orthobullets.com/topic/9050/images/pitting.jpg
https://upload.orthobullets.com/topic/9050/images/img_0247.jpg
Introduction
  • seronegative spondyloarthropathy that presents with the following orthopaedic manifestations 
    • 5 patterns of arthritis
      • asymmetric oligo/monoarticular arthritis affecting DIPJ, PIPJ, MCPJ
      • DIP-predominant arthritis
      • arthritis mutilans
      • symmetric, RF-negative polyarthritis
      • psoriatic spondyloarthropathy
  • Epidemiology
    • incidence
      • affect up to 5-20% of patients with psoriasis
    • demographics
      • equally affects men and women
  • Genetics
    • HLAB27 found in 50%
Presentation
  • Symptoms
    • arthritic symptoms in hands
  • Physical exam 
    • rash with silvery plaques over extensor surfaces (elbows, knees) 
      • typically precede joint involvement by several years (80-85% of time)
    • hands
      • dactylitis (sausage digit) 
      • onychodystrophy (nail pitting) 
      • onycholysis (lifting of nail plate starting distally)
      • arthritis mutilans 
        • opera glass hands (la main en lorgnette)
          • excess skin from the shortening of the phalanx bones becomes folded transversely, as if retracted into one another like opera glasses
    • chronic uveitis
    • entheses such as achilles tendonitis, posterior tibial tendonitis, and plantar fasciitis
Imaging
  • Radiographs 
    • hands
      • distal phalanx acrolysis 
      • DIP arthritis 
        • classic finding is "pencil-in-cup" deformity 
          • simultaneous destruction of the head of the middle phalanx and expansion of the base of the distal phalanx
        • different than DJD by presence of centripetal erosions which cause joint space widening
      • small joint erosions or fusions (PIP, MCP, and wrist commonly involved)
      • fluffy periostitis (caused by periosteal ossification)
      • acroosteolysis (resorption of the distal phalanx tuft) 
      • flail digits
    • spine in axial disease
      • sacroiliitis
      • syndesmophytes
      • paravertebral ossification
      • destructive discovertebral lesions
Studies
  • HLAB27 found in 50%
  • RA and ANA tests are usually negative
Treatment
  • Nonoperative
    • NSAIDS, methotrexate, sulfasalazine, cyclosporine,TNF-alpha inhibitors
      • indications
        • mainstay of treatment
          • similar to RA
  • Operative
    • digit fusion vs resection arthroplasty
      • indications
        • advanced joint disease
 

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Questions (4)

(OBQ17.129) A patient presents with the clinical images shown in Figures A-C. Which of the following is true? Tested Concept

QID: 210216
FIGURES:
1

Most patients with this skin condition develop arthritis

19%

(364/1872)

2

All patients that develop arthritis are positive for HLA-B27

6%

(119/1872)

3

The skin lesions respond well to systemic anti-fungal therapy

1%

(16/1872)

4

Rheumatoid factor and ANA are usually positive

18%

(337/1872)

5

DIP erosions are often centripetal

54%

(1014/1872)

L 4 A

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(OBQ11.158) A 32-year-old man has a 10-month history of bilateral toe swelling and foot pain. A clinical photo showing his toes is shown in Figure A. On examination of his feet he has tenderness along the posterior tibial tendon bilaterally which worsens with single-leg heel rise maneuvers. Standing radiographs of the feet are normal without deformity of the lesser toes. A clinical photo of his fingernails are shown in Figure B. Which of the following diagnoses is MOST likely? Tested Concept

QID: 3581
FIGURES:
1

Pseudogout (chondrocalcinosis)

3%

(99/3395)

2

Gout

3%

(113/3395)

3

Psoriatic arthritis

83%

(2817/3395)

4

Rheumatoid arthritis

1%

(32/3395)

5

Scleroderma (systemic sclerosis)

10%

(324/3395)

L 1 C

Select Answer to see Preferred Response

(OBQ10.241) A 47-year-old man complains of long standing pain involving the right index, middle, and ring fingers. A clinical image is shown in Figure A. A radiograph is provided in Figure B. Which of the following is the most likely diagnosis? Tested Concept

QID: 3340
FIGURES:
1

Gout

5%

(77/1599)

2

Osteoarthritis

2%

(33/1599)

3

Rheumatoid arthritis

6%

(101/1599)

4

Septic arthritis

0%

(3/1599)

5

Psoriatic arthritis

86%

(1379/1599)

L 1 C

Select Answer to see Preferred Response

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