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Findings The MRI shows an edema pattern within the left humeral head/greater tuberosity about the insertion of the left teres minor. Mild edema is present of the muscle. Subtle irregularity is present of the cortex. Only in retrospect, there is a suggestion of slight irregularity of the proximal left humerus on the radiographs. The contralateral right shoulder MRI is a nice comparison as no edema pattern is present of the bone and musculature and no irregularity of the bone is present at the teres minor insertion on the right side. The slight high signal of the humerus on the axial IR sequence was erythropoietic marrow of the metapysis.
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Diagnosis: Psoriatic Arthropathy The key portion of the history that was left out is that this is a patient with known psoriasis and psoriatic arthropathy who had stopped his TNF blocker a number of months ago and was now developing increasing pain. The absence of findings on the right side may relate to inability to perceive mild findings. The previously described seronegative arthropathies (not being positive for RF factor) or not rheumatoid arthritis arthropathies are now categorized as axial or peripheral spondyloarthritides. Whatever the classification, this group of arthritides are defined by enthesopathic changes. On MRI, this can manifest by edema in the bone and progressive erosions at attachment sites of ligaments or tendons which accounts for the irregular architecture of the left greater tuberosity. On radiographs, we frequently see erosions of the bone but also productive bony changes at the entheses. This is in distinction to rheumatoid arthritis where the productive bony changes are not found. Approximately 20% of patients with psoriasis will develop findings of psoriatic arthropathy. Given the extremely uncommon involvement of the teres minor in trauma, if there is edema or abnormality, thought should be given to alternative processes such as inflammatory arthropathy.
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References MRI Findings in Psoriatic Arthritis of the Hands. Daniel Spira, Ina Kötter, Jörg Henes, Jasmin Kümmerle-Deschner, Maximilian Schulze, Andreas Boss and Marius Horger. American Journal of Roentgenology. 2010;195: 1187-1193. 10.2214/AJR.10.4281
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