Alright, so we're seeing here
in indolent course
six months of increasing
pain and swelling.
That is a pretty typical picture
of psoriatic arthritis.
It's going to involve the fingers, the spine
and the sacred iliac joints.
Remember, we talked about that
finding on the finger
that was swollen the
Well, that feature is also
sausage shaped digits. If we were to
look at an MRI of that digit,
as shown here, on the bottom right, we
would see bone marrow edema.
You might see some interphalangeal
soft tissue, edema, and inflammation.
What we're really seeing in this
patient with a shortened index finger
is something called telescoping,
where the distal phalanx actually
collapses onto the middle
or proximal phalanx. This is a late finding
of psoriatic arthritis,
sometimes also known as arthritis mutilans.
the key point here is that it's particularly
destructive relative to
the other spondyloarthritides and
you can really have
some progressive joining deformities
if this disease goes untreated.
Highlighting again just
some key sites
where we see psoriatic arthritis involvement.
It's going to be the DIPs
and then perhaps some of the PIPs, but
not the MCPs or the wrists.
In addition, as shown in the right
picture by Vesalius,
you're going to see some involvement of the
lumbar spine and the SI joints.
Management pretty similar to the
you want to keep these people
moving with PT and OT,
get some NSAIDs on board, you're
probably going to add on
some disease modifying anti-rheumatic
drugs and likely some
TNF inhibitors, especially with a guy who's
got such advanced disease.
You want to move on beyond NSAID
and start being more aggressive.
All right now our key points
for psoriatic arthritis.
This is a chronic, progressive,
The classic features involved the
DIP joints, the SI joints
and you're going to see some
destructive erosive lesions
when you go looking
for them on X-ray.
More than 60% of patients have
concomitant skin psoriasis
at the time of diagnosis. More than
80% of them will have had
psoriasis at some point in the recent past.
It is a seronegative spondyloarthritis
most of the time, remember
that our patient
actually did have a low grade
The HLA b 27 positivity is associated
with psoriatic arthritis
though not quite as strongly as with
the other spondyloarthritides
and like all of the other ones
you're going to use NSAIDs
and next line would be