In station 5 you may be asked to assess a patient with joint pains.
HISTORY (3 minutes):
- Timing questions (sudden/gradual, since when, intermittent/constant, progression, previous episodes)
- Pattern of joint involvement (which joints, uni/bilateral, order they became affected in, large/small joints, back/neck pain)
- Joint pain/swelling/stiffness in the morning (how long for)/redness/deformity/nodules
- Function
- Extraarticular features of PsA:
- Nail changes and psoriasis
- Red/painful eye
- Plantar fasciitis, Achilles tendonitis, dactylitis (ever had a swollen finger/toe)
- Spondylitis specific questions if patient indicates back pain:
- When is back pain worst? Morning?
- Does exercise help?
- Stiff in morning? How long for?
- Do you wake in the night?
- Pain in buttock?
- Neck pain?
- Extraarticular features of RA:
- Systemic upset: fever, night sweats, weight loss, fatigue, lymph nodes
- Raynauds
- Skin, nails, hair: rashes, photosensitivity, hair loss, ulcers
- Eyes: dry/red/painful/change in vision
- CVS/Resp/GI/Neuro systems review
- PMH joint disease/psoriasis/IBD/autoimmune conditions
- Fx as above
- Dx treatments tried including NSAIDs
- Sx including impact
EXAMINE (3 minutes)
- Hand dorsum
- Swellings of MCP, PIP, wrist, redness, guttering of interossei, deformities (subluxation and ulnar deviation at MCPJs, subluxation of wrist, swan neck, Boutonnieres, z thumb deformities in RA/ RA-type PsA), nails (psoriasis, infarcts, vasculitis), thin and bruised skin (steroids), scars (carpal tunnel release, wrist arthrodesis, tendon transfer etc), rashes (psoriasis), dactylitis (psoriatic arthritis)
- Hand palm
- Palmer erythema, muscle wasting, scars
- Elbow
- Nodules, psoriatic plaques, gouty tophi, scars, bursitis
- Feel
- Palpate MCPJs, PIPJs, wrist for tenderness, swelling, temperature
- Feel the pulse
- Carpal tunnel tests if indicated (sensation, power, Tinel’s and Phalen’s tests)
- Feel over the elbows
- Move
- Ask to straighten fingers fully
- Ask to do prayer sign
- Ask to make a fist and hide your nails
- Grip my fingers and squeeze
- Pincer grip (make an O and don’t let me open it)
- Assess function eg. do a button, write, pick up a coin/glass.
- Put both hands behind your head
- Assess elbow and shoulder function if time allows as well as lower limb joints
- Look behind the ears and in the hair line and scalp for psoriasis
- Inspect the back from front, side, behind. Observe stooped question mark posture (loss of L lourdosis and fixed kyphosis with hyperextensions of C spine to maintain horizontal gaze)
- Palpate the spine- processes, muscles, SIJ
- Assess range of movement of the neck and back ROM
- Offer to perform Shobers test and assess the occiput-wall distance
- Look at the eyes: redness, conjunctival pallor
- Chest expansion, check for pacemaker, feel apex beat
- Listen for AR murmur, listen for apical creps
- Look at the abdomen for psoriasis around umbilicus
- Look at the feet- tendonitis, dactylitis
- Neuro- assess power, sensation, plantars if back pain
ICE and Explanation (2 minutes)
VIVA
Present to the examiner:
“This lady has a peripheral assymetrical deforming polyarthropathy. There is (no) active synovitis. The presence of psoriatic plaques and nail changes, dactylitis and enthesitis suggests psoriatic arthropathy. Hand function was preserved/limited. “
5-10% with psoriasis get PsA. Psoriasis precedes PsA by 8-10 years in 70%
PsA occurs simultaneously/precedes psoriasis in 30%
40% have a positive family history
Affects most often 35-50 year old males and females
Skin and joints can flare simultaneously/separately
Joint disease is most often peripheral (95%, synovitis, tenosynovitis, enthesitis). It can be axial only (5%). Patients can get a mixture of peripheral and axial disease
CASPAR criteria to diagnose (≥ 3 points):
- Psoriasis (current, past, Fx)
- Psoriatic nail dystrophy
- Negative Rheumatoid factor
- Dactylitis (current or past)
- XRay: juxtaarticular new bone formation
Subtypes (Moll and Wright 1973):
Assymetrical oligoarthritis 15-20% DIPJs+PIPJs, MCPJs+MTPJs, knee+hip, dactylitis
Predominantly DIPJ 2-5% Nail changes
Arthritis mutilans 5% Telescoping
RA-like 50-60% Wrist involvement
Axial (only) 2-5% Assymetrical sacroilitis
Think PsA (rather than RA) if:
- Assymetrical joint disease
- Rheumatoid Factor negative
- Psoriatic nail changes
- DIPJ involvement (and not osteoarthritis)
- Dactylitis, enthesitis
- Fx psoriasis/PsA
Extraarticular features of PsA:
- Nail involvement (80%)- pitting, ridging, onycholysis, hyperkeratosis
- Ocular involvement (conjunctivitis, iritis)
Differential Diagnoses: RA, other seronegative spondylarthritides (Ankylosing spondylitis, IBD arthritis, Reactive arthritis), OA, crystal arthritis (gout/pseudogout)
Investigations:
RF and anti-CCP (usually negative)
ANA (usually negative)
ESR/CRP (normal or increased)
FBC (anaemia), U+E (NSAIDs), LFT (pre-immunosupression)
Urine dipstick
HLA-B27 testing if sacroilitis
Joint aspirate: raised WCC, no culture/crystals
XRay: assymetrical changes, no periarticular osteopenia, DIPJ involvement, erosion of terminal tufts, pencil in cup deformity, sacroilitis, juxtaarticular new bone formation
Management:
Lifestyle advice: weight loss, exercise, smoking
NSAIDs
Steroid injection of joints/ligaments/tendons. Careful with steroids (risk skin flare!)
DMARD when NSAIDs fail, 3+ joints involved/PASI score>10 (methotrexate, sulfasalasine, leflunomide)
Anti-TNF agents
Ustekinumab (IL-23, IL-12 inhibitor)
Apremilast (PDE4 inhibitor)
Surgical: joint replacement
Dermatology opinion on skin disease (see “Station 5 Psoriasis and Eczema)
Written by Dr Sarah Kennedy
Resources used to write this document include those listed in the references section of this webpage and also:
Rheumatology Secrets by Sterling West