Physical trauma is generally accepted as a possible factor in the pathogenesis of
rheumatoid arthritis. In the last ten years, there have been a few rare case reports of
physical trauma precipitating psoriasic
arthritis. We observed two such cases following an occupational accident discovered one and a half year and two and a half year after onset of the first clinical manifestations. In the first case, a 43-year-old man had a fracture of the right calcaneus in March 1991. He was treated with nailing and also required emergency surgery of the posterior tibial artery. The tibiotarsal joint was normal radiologically.
Pain persisted
after treatment and in 1993 he presented with
psoriasis of the scalp and several other localizations together with Hallopeau's
acrodermatitis continua of the ankle, pathognomonic for psoriasic
arthritis. Salazosufapyridin was given. The second case was a 50-year-old man who had major
pain in both wrists immediately after falling on the palm of his hands in 1992. Bilateral
carpal tunnel syndrome developed which did not respond well to surgery. In 1993, he developed inflammatory
synovitis and also had
psoriasis mainly located at the elbows. Immunological tests were negative.
Cortisone and salazosulfapyridin were not particularly effective and the patient later developed
arthritis of the hip and ankle joints. Physicians should be aware of
physical trauma as a causative factor in psoriasic
arthritis due to the potential legal implications. Criteria for imputability are: single major
physical trauma, absence of clinical signs prior to the
trauma, continuous
clinical course, first signs occurring then predominating at the joint exposed to
trauma. The pathophysiology of this type of
arthritis is not well understood. Deep Koebner's phenomena could be involved. Activation of
substance P has also been hypothesized.