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The psoriatic hand
The psoriatic hand Thirty patients suffering from psoriatic arthritis of the hand are reviewed; they were an unselected sample from a general rheumatology practice. * All patients had an elevated sedimentation rate and an absence of rheumatoid factor. Antinuclear antibody was present in 13.3% of them. The severity of the skin or the nail changes did not correlate with the underlying joint involvement. Three clinical presentations of the disease are suggested as a guide in predicting the severity of the joint disease and selecting treatment.
Onaly A. Kapasi, M.D., Leonard K. Ruby, M.D., and Kristine Calney, O.T.R., Boston, Mass.
This study describes the natural history of psoriatic arthritis involving the hands. Psoriatic arthritis is, by definition, an inflammatory arthritis associated with skin manifestations of psoriasis and an absence of rheumatoid nodules. The disease may present with monoarticular or more commonly polyarticular involvement. Since its early description by Pierre Bazine and Bourdilon, its acceptance as a separate disease entity has followed an uneven course. Because of its similarity to rheumatoid arthritis, psoriasis has been grouped as a "seronegative" rheumatoid arthritis. t It is understood now that a certain percentage of patients with psoriatic arthritis present with a positive serology. 1 At times, psoriatic patients have joint changes without psoriatic skin rash, or the rash may be present in obscure areas such as the natal folds, perineum, or the scalp. These patients are most commonly misdiagnosed as having rheumatoid arthritis. As yet, there is no laboratory test available to absolutely confirm the diagnosis of psoriatic arthritis. Histocompatibility antigens such as HLAB-27, BW-38, and MLA-17 have been studied, but these antigens overlap among the different arthritides (Reiter's syndrome, rheumatoid, lupus, and psoriatic arthritis). 2-7 The presence of IgG antibodies to Chang human liver cells was noted in 3% of the patients with rheuma-
toid arthritis, whereas in patients with psoriatic arthritis, there were none. 8 Skin testing with various recall antigens, such as streptokinase-streptodornase, 9 and the ability to mount a primary cutaneous response to dinitrochlorobenzene in patients with psoriatic arthritis did not reveal any difference from the normal controls. lO Psychogenic factors have been studied in patients with "seronegative" arthritis and it is believed that some psychic factors playa role in etiology and pathogenesis of these arthritides ll - 13 and the severity of the joint involvement. 14 Relationships have also been noted by others between the severity of the skin changes and the joint involvement. I
From the Tufts University School of Medicine, Boston, Mass.
Results
Received for publication May 4, 1981.
Of the thirty patients, 13 were male and 17 female for a ratio of 1 : 1.3. The slightly higher female preponderance correlated well with other studies. 14, 15 This contrasts strikingly with rheumatoid arthritis, where the male-female ratio is 3: 1. The age of onset of the disease as noted among these patients was between 14 and 68 years, with an average of
Reprint requests: Onaly A. Kapasi, M.D., Clinical Instructor, Tufts University School of Medicine, 1180 Beacon Street, Brookline, MA 02146. *That of Dr. James Gowans, Rheumatologist, Tufts New England Medical Center Hospital, Boston, Mass. tSeropositive is defined as "Immunologically detectable levels of rheumatoid factor in significant titre. "
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THE JOURNAL OF HAND SURGERY
Material and methods This is a retrospective study of patients suffering from psoriatic arthritis involving the hands. Thirty patients have been studied-60 hands, 60 wrists, 60 thumbs, 240 metacarpophalangeal (MP) joints, and 240 distal interphalangeal (DIP) joints involved with psoriatic arthritis. Each patient was individually examined, and the past medical history and presentation of the disease were investigated. Only patients with confirmed diagnosis of psoriatic arthritis were selected. The patients with doubtful diagnosis were excluded. All the patients were being treated with either nonsteroidal anti-inflammatory drugs or methotrexate.
0363-5023/82/050492+06$00.6010
© 1982 American Society for Surgery of the Hand
Vol. 7, No.5 September 1982
The psoriatic hand
Type I
8
~ z UJ
~
~ o z
46.7%
.---
6
c...
r--
Type II Late skin and
,--
4
2
MILD
Early skin and Late joint changes
Peak Incidence r--
493
UNPREDICTABLE r--
30.0%
SEVERE
r--
Fig. 2. Three types of clinical presentations of psoriatic arthritis.
11-20
21-30
31-40 41-50
51-60
61-70
AGE OF ONSET Fig. 1. Age of onset of psoriatic arthritis.
40.96 years. The peak age of onset of this disease is between 20 and 40 years (Fig. 1). Cases of juvenile psoriatic arthritis have been described in the literature. 16 Serology. All the 30 patients had a routine antinuclear antibody (ANA), rheumatoid factor, and erythrocytic sedimentation rate (ESR) investigations. Of these, 86.7% of the patients presented with a negative serology ,* whereas the remaining 13.3% had a positive ANA test but a negative rheumatoid factor. All the patients had a high ESR at some stage of the disease, with values returning to normal during periods of remission. In contrast, Leonard et al. 1 noted a positive serologic response, i.e., ANA-positive in six out of 19 cases of psoriatic arthritis. Yet, other authors have quoted values as high as 50.17%. Therefore the only consistent laboratory value was an elevated ESR. Skin change. The psoriatic lesions were characterized by the presence of a sharply demarcated, erythematous rash with fine silvery scales. It has been noted that 7% of the patients with psoriasis have arthritiS.17 However, figures ranging from 6.8% to 32% have been quoted elsewhere in the literature. In this series, the patients presented with one of three clinical types. Type I patients had early skin changes with later joint changes. Type II patients had early joint changes with later skin changes with a delay between the two of 3 to
*Absence of ANA and rheumatoid factor.
4 years. Type III patients presented with simultaneous joint and skin changes. The joint changes were evaluated by clinical examination, functional disability, and roentgenograms (Fig. 2). Type I patients, those with early skin changes and later joint changes (14 or 46.7%), had mild arthritis. Type II patients, with early joint changes and later skin changes (10 or 30%), had severe arthritis. Type III patients, with simultaneous skin and joint changes (6 or 23.3%), had unpredictable involvement of the joints. The degree of arthritis was measured by the presence of stiffness, limitation of function, and radiological changes. The severity of the skin or nail changes was not indicative of the severity of the underlying joint changes, although some authors have noted a relationship between the two. IS Also of note is the fact that only the patients in clinical types II and III had mutilating forms of arthritis. Nail changes. All the patients in this study had some form of psoriatic nail changes. We could not see any relationship between the severity of the nail involvement and the joint changes, although this has been noted by some. 14 Fig. 3 shows some of the typical nail changes; these changes are best enumerated by Zaias. 19 They are as follows: 1. Nail plate. Pits, tranverse depressions, crumbling nail plate and leuconcychia. 2. Nail bed. Splinter hemorrhage, large red patches. 3. Hyponychium. Subungual keratosis, yellow-green subungual debris and onycholysis. Arthritis. There was an absence of uniformity in the location of joint changes; that is, a patient could present with DIP joint involvement in one hand and a more generalized disease of the opposite hand involving the DIP, PIP, and MP joints. The patients in this study did
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The Journal of HAND SURGERY
Kapasi, Ruby, alld Calney
Fig. 3. Nail changes in psoriatic arthritis.
Fig. 5. Case of severe involvement of wrist joint. Also associated is an adduction defonnity of the thumb .
Group 1
Digital joints 36.7%
Group 2
Generalized (axial + digital) 63.3%
Fig. 4. Joint involvement. Generalized joint involvement is a more frequent presentation than mentioned in the earlier literature .
not readily fall into the five clinical groups as described by Moll and Wright l4 : Wright type I patients presenting with classical psoriatic arthritis with predominantly DIP joint involvement, type II patients presenting with arthritis mutilans, type III patients presenting with symmetrical arthritis similar to rheumatoid arthritis, type IV patients presenting with single or few finger and toe joint involvement, and type V characterized by the involvement of ankylosing spondylitis as a predominant feature. In this study, we could divide the patients into two major joint types: (1) a group of patients pre-
senting with predominant involvement of the digital joints and (2) a group of patients presenting with a generalized psoriatic arthritis involving the digital joints as well as sacroiliac joint and other major joints of the body20 (Fig. 4). Wrist. Out of the 60 wrists examined, 35% were involved with arthritis. The wrist involvement could be broadly divided into: (1) synovitis and (2) deformity. Out of the total number of wrists, six wrists or 10% showed synovitis. Radial deviation was noted in 15 wrists or 25% of the total. Out of these, five wrists or 8.3% of the total also had an associated palmar subluxation (Fig. 5). Thumb. Of 60 thumbs examined, only 20% or 12 thumbs had carpometacarpal joint involvement. This was associated with an adduction deformity of the thumb, with a decreased first web space. Twenty-nine thumbs, 48 .3% of the total, were noted to have a flexion deformity of the MP joints. Of these, 26 (43.3%) had an associated hyperextension of the interphalangeal joint (Fig. 6). These patients had difficulty with the tip-to-tip pinch. Four (6.7%) of the patients with adduction deformity of the thumb also had MP hyperextension deformity that was not associated with any other deformity in the thumb. Fingers. The various deformities seen in the fingers are described by the joint involvement. MP joint involvement. The total number of MP joints involved was 27.5%, or a total of 66 MP joints out of 240 joints examined (Fig. 7) . Synovitis was
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The psoriatic hand
495
Total MCP Involvement 27 .5%
P= Palmar subluxation U= Ulnar deviation F= Flexion contracture
Fig. 7. Involvement of the MP (Me?) joints.
Fig. 6. Deformity of thumb . Flexion deformity of the MP joint and hyperextension of the interphalangeal joint is a common deformity of the thumb.
noted in 5% of the total joints. Palmar subluxation associated with flexion contracture and ulnar drift was noted in 32 MP joints, or 13.3% of the total MP joints. Twenty-two MP joints (9.2%) had flexion contracture associated with ulnar drift but without any palmar subluxation. PIP joint involvement. This joint was as commonly involved as the distal joint. Fifty-one percent of the PIP joints were involved with synovitis, deformity, or both. Hyperextension associated with swan-neck deformities was noted in the case of 15 % or 36 of the total fingers. flexion deformity associated with the boutonniere deformity was noted in 9.6% or 23 of the total fingers . flexion deformity without hyperextension of the DIP was noted in 22.1 % of the total joints examined. Synovitis was noted in the case of 13.3% of the total number of joints examined, 32/240. The commonest deformity was a flexion deformity at the PIP joint without any DIP hyperextension . Some of the flexion deformities were associated with opera-glass ("main-en-lorgnette' ') deformity. Synovitis presented as an isolated PIP joint swelling or as a diffuse fusiform swelling of a finger, so called "sausage finger. " DIP joint involvement. Out of the 240 DIP joints examined, 51.3% were involved, (Fig. 8). A flexion deformity was noted with 27.5% of the joints. Some of these were associated with swan-neck deformities of the fingers. The rest presented as a primary "mallet" deformity, i.e., DIP flexion without any PIP hy-
No DIP joint involvement 62 .9% Flexion 27.5%
Fig. 8. DIP joint involvement.
perextension. A smaller number of patients (9.6%) presented with hyperextension at the DIP joints. Ankylosis of the joint was also a common finding with DIP joint involvement. When ankylosis was present, the joint was ankylosed in neutral position, ulnar deviation, or radial deviation . Tendon and nerve involvement. Tendon involvement was found to be remarkably low. Two patients had ruptures of the extensor pollicis brevis tendons. One patient had a rupture of the flexor digitorum superficialis to the ring finger . Thus a total of three patients, i.e., 5% of all hands, had tendon involvement. Four hands in three patients revealed some hypes-
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Kapasi, Ruby, alld Calney
thesia along the median nerve distribution of the hand, suggesting a carpal tunnel syndrome. Discussion
The diagnosis of psoriatic arthritis is one of exclusion. Patients presenting with arthritis associated with the typical psoriatic skin lesions in the absence of significant levels of rheumatoid factor should be labeled as psoriatic arthritis patients. The slightly higher female preponderance correlates well with results of other studies. Although rare, the incidence of juvenile psoriatic arthritis has been reported. The youngest patient in our series is a 14-year-old female. A small percentage of the patients (13.3%) in this series had a positive ANA test. These patients were labeled as having seronegative arthritis and later diagnosed as having psoriatic arthritis, since the skin lesions were present in obscure areas and therefore missed or the skin lesions made a late appearance. The three clinical types described in the text have prognostic as well as therapeutic significance. Patients grouped as clinical type I develop a mild form of joint disease. Also, the underlying joint lesion has no correlation with the severity of the cutaneous lesion. These patients are best treated with anti-inflammatory medication, physical therapy, and splinting of the joints to prevent deformities. Patients grouped as clinical type II develop a progressive and mutilating form of joint disease. However, these patients present with joint disease preceding the skin lesions and are therefore a diagnostic enigma. Such patients should be treated to avoid loss of function and prevent deformities. With the appearance of skin lesions, the diagnosis is confirmed. Thereafter, aggressive surgical treatment consisting of interposition arthroplasties in combination with fusion should be undertaken. This should be carried out prior to the development of pencil-in-cup deformities, whittling, severe osteolysis, and main-en-lorgnette deformities. Reconstructive surgery in late stages is technically difficult and offers suboptimal results. Similarily it has been noted that some patients grouped as clinical type III progress to develop mutilating arthritis. There is no clear-cut formula to preselect these patients, but with the knowledge of the three clinical presentations and a frequent review of the progressive cases, one should be able to offer a better judgment than in the past. Also, it has been noted that severe wrist and MP deformities are seen in the mutilating form of the disease. This should raise an index of suspicion. Generally speaking, polyarthritis involving the spine and the sacroiliac and tempomandibular joints was seen
The Journal of HAND SURGERY
more frequently than previously believed. The probable reasons were a benign neglect of the less symptomatic joint involvement and the fact that the hand deformities were cosmetically more obvious and functionally more disabling. The wrist joint was quite frequently involved (35%). The commonest deformity was radial deviation (25%). Some of these (8.3%) were associated with a palmar collapse. This latter deformity was seen only in patients suffering from severe joint disease, i.e., clinical type II and some type III. The thumb presented with severe functional involvement because of the adduction deformity at the carpometacarpal joint and an associated MP joint flexion or extension deformity. The interphalangeal hyperextension caused a loss of tip-to-tip pinch and a weaker key pinch. The functional disability was directly related to the combination of the above mentioned deformities. Ulnar deviation at the MP joint was seen more frequently than a combination of ulnar deviation with palmar subluxation. The latter deformity was seen predominantly in the clinical type II patient and the severe joint types in clinical type III. Psoriatic arthritis had a greater propensity for affecting the PIP and DIP joints than the carpal or the MP joints. Pure flexion deformity was frequently encountered. Less frequently, flexion of the PIP joint was seen in association with a boutonniere deformity of the finger. However, hyperextension of the PIP joint was seen only in association with swan-neck deformities of the fingers. This observation along with the significantly higher incidence of the flexion deformity of the DIP joint raises the question of whether the swanneck deformities may be a sequel of a primary flexion deformity of the DIP joint. Synovitis and swelling of the PIP joint were seen more often than of any other joints. The classic deformity was a fusiform swelling with its maximum girth at the PIP joint and tapering at the either ends. Pencil-in-cup deformity, secondary to severe osteolysis with associated telescopic deformities, was seen in 24 fingers. Contrary to the popular opinion, this main-en-lorgnette deformity is not a characteristic feature of psoriatic arthritis, since as it is also noted in patients with severe rheumatoid arthritis.21 DIP joint disease was seen in 51. 3% of the total joints. Ankylosis of the joint was a common presentation. The joints were ankylosed in flexion, ulnar, or radial deviations. Those patients with deviating ankylosis were unable to bring the fingers together in a fist because of overlapping and loss of alignment. They performed poorly in picking up coins from flat sur-
Vol. 7, No.5 September 1982
faces. Surprisingly, tendon ruptures were infrequently noted in spite of the osteolysis and whittling of the bones. This is probably related to the generalized lower incidence of tenosynovitis noted in this disease.
Summary and conclusion Thirty patients suffering from psoriatic arthritis of the hand have been reported. The most common involvement of the hand is at the PIP and DIP joints. Nerve and tendon involvement were rare. Because of the clinical similarity of the deformities and the absence of confirmatory laboratory investigations, these patients have often been misdiagnosed as having rheumatoid arthritis. Three distinguishable clinical presentations are suggested in this small series. It may be possible to predict the prognosis of the disease and plan the treatment. We suggest that type I presentation should be treated nonoperatively. Patients with type II presentation should be considered for operative correction prior to the development of crippling deformities, and the patients with type III presentation should be watched closely for conversion into the severe joint type. REFERENCES 1. Leonard DG, O'Duffy JD, Rogers RS: Prospective analysis of psoriatic arthritis in patients hospitalized for psoriasis. Mayo Clin Proc 53:511-8, 1978 2. Marcusson J, Moller E, Thyresson N: HL-A antigens (17, 27 Ups) in psoriasis with special reference to patients with arthritic lesions. Acta Derm Venereol 55: 297-300, 1975 3. Zachariae H, Friis J, Gradaudal H, Hjortsh lA, Kissmeyer-Nielsen F, Svejgaard E, Zachariae E: Reiter's disease and the histocompatibility antigen, HL-A 27. Scand J Rheumatol 4: 13-5, 1975 4. Metzger AL, Morris RI, Bluestone R, Terasaki PI: HL-A W27 in psoriatic arthropathy. Arthritis Rheum 18: 111-5, 1975 5. Karvonen J, Lassus A, Sievers U, Tiilikainen A: HL-A antigens in psoriatic arthritis. Ann Clin Res 6: 304-7, 1974
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6. Schumaker TM, Genant HK, Kellet JJ, Mall JC, Fye KH: HL-A B27 associates arthropathies. Radiology 126: 289-97, 1978 7. Espinoza LR, Vasey FB, Oh JH, Wilkinson R, Osterland CK: Association between HL-A BW 38 and peripheral psoriatic arthritis. Arthritis Rheum 21:72-5, 1978 8. Panayi GS: Antibody-mediated leucocyte cytotoxicity to chang human liver cells in rheumatoid arthritis and other diseases. Ann Rheum Dis 35:27-31, 1976 9. Frobel K, Strurrock RD, Dick WC, Macsween RN: Cell-mediated immunity in the rheumatoid diseases. I. Skin testing and mitogenic responses in sero-negative arthritides. Clin Exp Immunol 22:446-52, 1975 10. Lambert JR, Roberts M, Wright V: Nitroblue tetrazolium test in psoriatic arthritis, rheumatoid arthritis and osteoarthritis. Ann Rheum Dis 37:363-5, 1978 II. Zander W: Problem of specific syndrome formation in psychosomatic disease situations (Psychodynamics of Rheumatic Diseases). Psychosom Med Psychoanal 22:50-68, 1976 12. Zander W: Psychodynamic factors in some rheumatoid factor negative arthritic diseases. Munch Med Wochenschr 117: 1475-8, 1975 13. Pfitzner R: Psychodynamic aspects of several rheumatic diseases as revealed in tests. Z Psychos om Med Psychanal 22:356-63, 1976 14. Moll IMH, Wright V: Psoriatic arthritis. Semin Arthritis Rheum 3:55-78, 1973 15. Roberts ME, Wright V, Hill AG, Mehra AC: Psoriatic arthritis follow-up study. Ann Rheum Dis 35:206-12, 1976 16. Chiappo GF, Balbo L, Oggero R, Mignone F: Psoriatic polyarthritis in childhood. Clinico-nosological study. Arch Sci Med 134:407-12, 1977 17. Anderson TF, Vorhees JJ: Psoriasis and arthritis. Cutis 21:790-4, 800, 1978 18. Little H, Harvie IN, Lester RS: Psoriatic arthritis in severe psoriasis. Can Med Assoc I 112:317-9, 1975 19. Zaias N: Psoriasis of the nail: A clinicopatholigical study. Arch Derm 99:567, 1969 20. O'Duffy JD: Psoriatic arthritis. Postgrad Med 61:65-71, 1977 21. Nalebuff EA, Garrett 1: Opera glass hand in rheumatoid arthritis. 1:210-20, 1976
Onaly A. Kapasi, M.D., Leonard K. Ruby, M.D., and Kristine Calney, O.T.R., Boston, Mass.
This study describes the natural history of psoriatic arthritis involving the hands. Psoriatic arthritis is, by definition, an inflammatory arthritis associated with skin manifestations of psoriasis and an absence of rheumatoid nodules. The disease may present with monoarticular or more commonly polyarticular involvement. Since its early description by Pierre Bazine and Bourdilon, its acceptance as a separate disease entity has followed an uneven course. Because of its similarity to rheumatoid arthritis, psoriasis has been grouped as a "seronegative" rheumatoid arthritis. t It is understood now that a certain percentage of patients with psoriatic arthritis present with a positive serology. 1 At times, psoriatic patients have joint changes without psoriatic skin rash, or the rash may be present in obscure areas such as the natal folds, perineum, or the scalp. These patients are most commonly misdiagnosed as having rheumatoid arthritis. As yet, there is no laboratory test available to absolutely confirm the diagnosis of psoriatic arthritis. Histocompatibility antigens such as HLAB-27, BW-38, and MLA-17 have been studied, but these antigens overlap among the different arthritides (Reiter's syndrome, rheumatoid, lupus, and psoriatic arthritis). 2-7 The presence of IgG antibodies to Chang human liver cells was noted in 3% of the patients with rheuma-
toid arthritis, whereas in patients with psoriatic arthritis, there were none. 8 Skin testing with various recall antigens, such as streptokinase-streptodornase, 9 and the ability to mount a primary cutaneous response to dinitrochlorobenzene in patients with psoriatic arthritis did not reveal any difference from the normal controls. lO Psychogenic factors have been studied in patients with "seronegative" arthritis and it is believed that some psychic factors playa role in etiology and pathogenesis of these arthritides ll - 13 and the severity of the joint involvement. 14 Relationships have also been noted by others between the severity of the skin changes and the joint involvement. I
From the Tufts University School of Medicine, Boston, Mass.
Results
Received for publication May 4, 1981.
Of the thirty patients, 13 were male and 17 female for a ratio of 1 : 1.3. The slightly higher female preponderance correlated well with other studies. 14, 15 This contrasts strikingly with rheumatoid arthritis, where the male-female ratio is 3: 1. The age of onset of the disease as noted among these patients was between 14 and 68 years, with an average of
Reprint requests: Onaly A. Kapasi, M.D., Clinical Instructor, Tufts University School of Medicine, 1180 Beacon Street, Brookline, MA 02146. *That of Dr. James Gowans, Rheumatologist, Tufts New England Medical Center Hospital, Boston, Mass. tSeropositive is defined as "Immunologically detectable levels of rheumatoid factor in significant titre. "
492
THE JOURNAL OF HAND SURGERY
Material and methods This is a retrospective study of patients suffering from psoriatic arthritis involving the hands. Thirty patients have been studied-60 hands, 60 wrists, 60 thumbs, 240 metacarpophalangeal (MP) joints, and 240 distal interphalangeal (DIP) joints involved with psoriatic arthritis. Each patient was individually examined, and the past medical history and presentation of the disease were investigated. Only patients with confirmed diagnosis of psoriatic arthritis were selected. The patients with doubtful diagnosis were excluded. All the patients were being treated with either nonsteroidal anti-inflammatory drugs or methotrexate.
0363-5023/82/050492+06$00.6010
© 1982 American Society for Surgery of the Hand
Vol. 7, No.5 September 1982
The psoriatic hand
Type I
8
~ z UJ
~
~ o z
46.7%
.---
6
c...
r--
Type II Late skin and
,--
4
2
MILD
Early skin and Late joint changes
Peak Incidence r--
493
UNPREDICTABLE r--
30.0%
SEVERE
r--
Fig. 2. Three types of clinical presentations of psoriatic arthritis.
11-20
21-30
31-40 41-50
51-60
61-70
AGE OF ONSET Fig. 1. Age of onset of psoriatic arthritis.
40.96 years. The peak age of onset of this disease is between 20 and 40 years (Fig. 1). Cases of juvenile psoriatic arthritis have been described in the literature. 16 Serology. All the 30 patients had a routine antinuclear antibody (ANA), rheumatoid factor, and erythrocytic sedimentation rate (ESR) investigations. Of these, 86.7% of the patients presented with a negative serology ,* whereas the remaining 13.3% had a positive ANA test but a negative rheumatoid factor. All the patients had a high ESR at some stage of the disease, with values returning to normal during periods of remission. In contrast, Leonard et al. 1 noted a positive serologic response, i.e., ANA-positive in six out of 19 cases of psoriatic arthritis. Yet, other authors have quoted values as high as 50.17%. Therefore the only consistent laboratory value was an elevated ESR. Skin change. The psoriatic lesions were characterized by the presence of a sharply demarcated, erythematous rash with fine silvery scales. It has been noted that 7% of the patients with psoriasis have arthritiS.17 However, figures ranging from 6.8% to 32% have been quoted elsewhere in the literature. In this series, the patients presented with one of three clinical types. Type I patients had early skin changes with later joint changes. Type II patients had early joint changes with later skin changes with a delay between the two of 3 to
*Absence of ANA and rheumatoid factor.
4 years. Type III patients presented with simultaneous joint and skin changes. The joint changes were evaluated by clinical examination, functional disability, and roentgenograms (Fig. 2). Type I patients, those with early skin changes and later joint changes (14 or 46.7%), had mild arthritis. Type II patients, with early joint changes and later skin changes (10 or 30%), had severe arthritis. Type III patients, with simultaneous skin and joint changes (6 or 23.3%), had unpredictable involvement of the joints. The degree of arthritis was measured by the presence of stiffness, limitation of function, and radiological changes. The severity of the skin or nail changes was not indicative of the severity of the underlying joint changes, although some authors have noted a relationship between the two. IS Also of note is the fact that only the patients in clinical types II and III had mutilating forms of arthritis. Nail changes. All the patients in this study had some form of psoriatic nail changes. We could not see any relationship between the severity of the nail involvement and the joint changes, although this has been noted by some. 14 Fig. 3 shows some of the typical nail changes; these changes are best enumerated by Zaias. 19 They are as follows: 1. Nail plate. Pits, tranverse depressions, crumbling nail plate and leuconcychia. 2. Nail bed. Splinter hemorrhage, large red patches. 3. Hyponychium. Subungual keratosis, yellow-green subungual debris and onycholysis. Arthritis. There was an absence of uniformity in the location of joint changes; that is, a patient could present with DIP joint involvement in one hand and a more generalized disease of the opposite hand involving the DIP, PIP, and MP joints. The patients in this study did
494
The Journal of HAND SURGERY
Kapasi, Ruby, alld Calney
Fig. 3. Nail changes in psoriatic arthritis.
Fig. 5. Case of severe involvement of wrist joint. Also associated is an adduction defonnity of the thumb .
Group 1
Digital joints 36.7%
Group 2
Generalized (axial + digital) 63.3%
Fig. 4. Joint involvement. Generalized joint involvement is a more frequent presentation than mentioned in the earlier literature .
not readily fall into the five clinical groups as described by Moll and Wright l4 : Wright type I patients presenting with classical psoriatic arthritis with predominantly DIP joint involvement, type II patients presenting with arthritis mutilans, type III patients presenting with symmetrical arthritis similar to rheumatoid arthritis, type IV patients presenting with single or few finger and toe joint involvement, and type V characterized by the involvement of ankylosing spondylitis as a predominant feature. In this study, we could divide the patients into two major joint types: (1) a group of patients pre-
senting with predominant involvement of the digital joints and (2) a group of patients presenting with a generalized psoriatic arthritis involving the digital joints as well as sacroiliac joint and other major joints of the body20 (Fig. 4). Wrist. Out of the 60 wrists examined, 35% were involved with arthritis. The wrist involvement could be broadly divided into: (1) synovitis and (2) deformity. Out of the total number of wrists, six wrists or 10% showed synovitis. Radial deviation was noted in 15 wrists or 25% of the total. Out of these, five wrists or 8.3% of the total also had an associated palmar subluxation (Fig. 5). Thumb. Of 60 thumbs examined, only 20% or 12 thumbs had carpometacarpal joint involvement. This was associated with an adduction deformity of the thumb, with a decreased first web space. Twenty-nine thumbs, 48 .3% of the total, were noted to have a flexion deformity of the MP joints. Of these, 26 (43.3%) had an associated hyperextension of the interphalangeal joint (Fig. 6). These patients had difficulty with the tip-to-tip pinch. Four (6.7%) of the patients with adduction deformity of the thumb also had MP hyperextension deformity that was not associated with any other deformity in the thumb. Fingers. The various deformities seen in the fingers are described by the joint involvement. MP joint involvement. The total number of MP joints involved was 27.5%, or a total of 66 MP joints out of 240 joints examined (Fig. 7) . Synovitis was
Vol. 7. No . 5 September 1982
The psoriatic hand
495
Total MCP Involvement 27 .5%
P= Palmar subluxation U= Ulnar deviation F= Flexion contracture
Fig. 7. Involvement of the MP (Me?) joints.
Fig. 6. Deformity of thumb . Flexion deformity of the MP joint and hyperextension of the interphalangeal joint is a common deformity of the thumb.
noted in 5% of the total joints. Palmar subluxation associated with flexion contracture and ulnar drift was noted in 32 MP joints, or 13.3% of the total MP joints. Twenty-two MP joints (9.2%) had flexion contracture associated with ulnar drift but without any palmar subluxation. PIP joint involvement. This joint was as commonly involved as the distal joint. Fifty-one percent of the PIP joints were involved with synovitis, deformity, or both. Hyperextension associated with swan-neck deformities was noted in the case of 15 % or 36 of the total fingers. flexion deformity associated with the boutonniere deformity was noted in 9.6% or 23 of the total fingers . flexion deformity without hyperextension of the DIP was noted in 22.1 % of the total joints examined. Synovitis was noted in the case of 13.3% of the total number of joints examined, 32/240. The commonest deformity was a flexion deformity at the PIP joint without any DIP hyperextension . Some of the flexion deformities were associated with opera-glass ("main-en-lorgnette' ') deformity. Synovitis presented as an isolated PIP joint swelling or as a diffuse fusiform swelling of a finger, so called "sausage finger. " DIP joint involvement. Out of the 240 DIP joints examined, 51.3% were involved, (Fig. 8). A flexion deformity was noted with 27.5% of the joints. Some of these were associated with swan-neck deformities of the fingers. The rest presented as a primary "mallet" deformity, i.e., DIP flexion without any PIP hy-
No DIP joint involvement 62 .9% Flexion 27.5%
Fig. 8. DIP joint involvement.
perextension. A smaller number of patients (9.6%) presented with hyperextension at the DIP joints. Ankylosis of the joint was also a common finding with DIP joint involvement. When ankylosis was present, the joint was ankylosed in neutral position, ulnar deviation, or radial deviation . Tendon and nerve involvement. Tendon involvement was found to be remarkably low. Two patients had ruptures of the extensor pollicis brevis tendons. One patient had a rupture of the flexor digitorum superficialis to the ring finger . Thus a total of three patients, i.e., 5% of all hands, had tendon involvement. Four hands in three patients revealed some hypes-
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thesia along the median nerve distribution of the hand, suggesting a carpal tunnel syndrome. Discussion
The diagnosis of psoriatic arthritis is one of exclusion. Patients presenting with arthritis associated with the typical psoriatic skin lesions in the absence of significant levels of rheumatoid factor should be labeled as psoriatic arthritis patients. The slightly higher female preponderance correlates well with results of other studies. Although rare, the incidence of juvenile psoriatic arthritis has been reported. The youngest patient in our series is a 14-year-old female. A small percentage of the patients (13.3%) in this series had a positive ANA test. These patients were labeled as having seronegative arthritis and later diagnosed as having psoriatic arthritis, since the skin lesions were present in obscure areas and therefore missed or the skin lesions made a late appearance. The three clinical types described in the text have prognostic as well as therapeutic significance. Patients grouped as clinical type I develop a mild form of joint disease. Also, the underlying joint lesion has no correlation with the severity of the cutaneous lesion. These patients are best treated with anti-inflammatory medication, physical therapy, and splinting of the joints to prevent deformities. Patients grouped as clinical type II develop a progressive and mutilating form of joint disease. However, these patients present with joint disease preceding the skin lesions and are therefore a diagnostic enigma. Such patients should be treated to avoid loss of function and prevent deformities. With the appearance of skin lesions, the diagnosis is confirmed. Thereafter, aggressive surgical treatment consisting of interposition arthroplasties in combination with fusion should be undertaken. This should be carried out prior to the development of pencil-in-cup deformities, whittling, severe osteolysis, and main-en-lorgnette deformities. Reconstructive surgery in late stages is technically difficult and offers suboptimal results. Similarily it has been noted that some patients grouped as clinical type III progress to develop mutilating arthritis. There is no clear-cut formula to preselect these patients, but with the knowledge of the three clinical presentations and a frequent review of the progressive cases, one should be able to offer a better judgment than in the past. Also, it has been noted that severe wrist and MP deformities are seen in the mutilating form of the disease. This should raise an index of suspicion. Generally speaking, polyarthritis involving the spine and the sacroiliac and tempomandibular joints was seen
The Journal of HAND SURGERY
more frequently than previously believed. The probable reasons were a benign neglect of the less symptomatic joint involvement and the fact that the hand deformities were cosmetically more obvious and functionally more disabling. The wrist joint was quite frequently involved (35%). The commonest deformity was radial deviation (25%). Some of these (8.3%) were associated with a palmar collapse. This latter deformity was seen only in patients suffering from severe joint disease, i.e., clinical type II and some type III. The thumb presented with severe functional involvement because of the adduction deformity at the carpometacarpal joint and an associated MP joint flexion or extension deformity. The interphalangeal hyperextension caused a loss of tip-to-tip pinch and a weaker key pinch. The functional disability was directly related to the combination of the above mentioned deformities. Ulnar deviation at the MP joint was seen more frequently than a combination of ulnar deviation with palmar subluxation. The latter deformity was seen predominantly in the clinical type II patient and the severe joint types in clinical type III. Psoriatic arthritis had a greater propensity for affecting the PIP and DIP joints than the carpal or the MP joints. Pure flexion deformity was frequently encountered. Less frequently, flexion of the PIP joint was seen in association with a boutonniere deformity of the finger. However, hyperextension of the PIP joint was seen only in association with swan-neck deformities of the fingers. This observation along with the significantly higher incidence of the flexion deformity of the DIP joint raises the question of whether the swanneck deformities may be a sequel of a primary flexion deformity of the DIP joint. Synovitis and swelling of the PIP joint were seen more often than of any other joints. The classic deformity was a fusiform swelling with its maximum girth at the PIP joint and tapering at the either ends. Pencil-in-cup deformity, secondary to severe osteolysis with associated telescopic deformities, was seen in 24 fingers. Contrary to the popular opinion, this main-en-lorgnette deformity is not a characteristic feature of psoriatic arthritis, since as it is also noted in patients with severe rheumatoid arthritis.21 DIP joint disease was seen in 51. 3% of the total joints. Ankylosis of the joint was a common presentation. The joints were ankylosed in flexion, ulnar, or radial deviations. Those patients with deviating ankylosis were unable to bring the fingers together in a fist because of overlapping and loss of alignment. They performed poorly in picking up coins from flat sur-
Vol. 7, No.5 September 1982
faces. Surprisingly, tendon ruptures were infrequently noted in spite of the osteolysis and whittling of the bones. This is probably related to the generalized lower incidence of tenosynovitis noted in this disease.
Summary and conclusion Thirty patients suffering from psoriatic arthritis of the hand have been reported. The most common involvement of the hand is at the PIP and DIP joints. Nerve and tendon involvement were rare. Because of the clinical similarity of the deformities and the absence of confirmatory laboratory investigations, these patients have often been misdiagnosed as having rheumatoid arthritis. Three distinguishable clinical presentations are suggested in this small series. It may be possible to predict the prognosis of the disease and plan the treatment. We suggest that type I presentation should be treated nonoperatively. Patients with type II presentation should be considered for operative correction prior to the development of crippling deformities, and the patients with type III presentation should be watched closely for conversion into the severe joint type. REFERENCES 1. Leonard DG, O'Duffy JD, Rogers RS: Prospective analysis of psoriatic arthritis in patients hospitalized for psoriasis. Mayo Clin Proc 53:511-8, 1978 2. Marcusson J, Moller E, Thyresson N: HL-A antigens (17, 27 Ups) in psoriasis with special reference to patients with arthritic lesions. Acta Derm Venereol 55: 297-300, 1975 3. Zachariae H, Friis J, Gradaudal H, Hjortsh lA, Kissmeyer-Nielsen F, Svejgaard E, Zachariae E: Reiter's disease and the histocompatibility antigen, HL-A 27. Scand J Rheumatol 4: 13-5, 1975 4. Metzger AL, Morris RI, Bluestone R, Terasaki PI: HL-A W27 in psoriatic arthropathy. Arthritis Rheum 18: 111-5, 1975 5. Karvonen J, Lassus A, Sievers U, Tiilikainen A: HL-A antigens in psoriatic arthritis. Ann Clin Res 6: 304-7, 1974
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6. Schumaker TM, Genant HK, Kellet JJ, Mall JC, Fye KH: HL-A B27 associates arthropathies. Radiology 126: 289-97, 1978 7. Espinoza LR, Vasey FB, Oh JH, Wilkinson R, Osterland CK: Association between HL-A BW 38 and peripheral psoriatic arthritis. Arthritis Rheum 21:72-5, 1978 8. Panayi GS: Antibody-mediated leucocyte cytotoxicity to chang human liver cells in rheumatoid arthritis and other diseases. Ann Rheum Dis 35:27-31, 1976 9. Frobel K, Strurrock RD, Dick WC, Macsween RN: Cell-mediated immunity in the rheumatoid diseases. I. Skin testing and mitogenic responses in sero-negative arthritides. Clin Exp Immunol 22:446-52, 1975 10. Lambert JR, Roberts M, Wright V: Nitroblue tetrazolium test in psoriatic arthritis, rheumatoid arthritis and osteoarthritis. Ann Rheum Dis 37:363-5, 1978 II. Zander W: Problem of specific syndrome formation in psychosomatic disease situations (Psychodynamics of Rheumatic Diseases). Psychosom Med Psychoanal 22:50-68, 1976 12. Zander W: Psychodynamic factors in some rheumatoid factor negative arthritic diseases. Munch Med Wochenschr 117: 1475-8, 1975 13. Pfitzner R: Psychodynamic aspects of several rheumatic diseases as revealed in tests. Z Psychos om Med Psychanal 22:356-63, 1976 14. Moll IMH, Wright V: Psoriatic arthritis. Semin Arthritis Rheum 3:55-78, 1973 15. Roberts ME, Wright V, Hill AG, Mehra AC: Psoriatic arthritis follow-up study. Ann Rheum Dis 35:206-12, 1976 16. Chiappo GF, Balbo L, Oggero R, Mignone F: Psoriatic polyarthritis in childhood. Clinico-nosological study. Arch Sci Med 134:407-12, 1977 17. Anderson TF, Vorhees JJ: Psoriasis and arthritis. Cutis 21:790-4, 800, 1978 18. Little H, Harvie IN, Lester RS: Psoriatic arthritis in severe psoriasis. Can Med Assoc I 112:317-9, 1975 19. Zaias N: Psoriasis of the nail: A clinicopatholigical study. Arch Derm 99:567, 1969 20. O'Duffy JD: Psoriatic arthritis. Postgrad Med 61:65-71, 1977 21. Nalebuff EA, Garrett 1: Opera glass hand in rheumatoid arthritis. 1:210-20, 1976