What is Dupuytren's contracture?
Connective tissue disorder where the specialized palmar fascia undergoes hyperplasia with normal fascial bands forming nodulesand cords progressing to contractures at the MCP and PIP joints.
What disorder is shown ?
Describe the pathology of duputyrens contracture
- Involves proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1).
- Palpable nodules may be present
What fingers are most commonly affected by duputyrens contracture ?
Most commonly affect the ring and little fingers.
Describe the epidemiology of duputyrens contracture:
who is most commonly affected and its inheritance?
- Males (10:1)
- Can be familial (inherited in autosomal dominant manner)
- Can be seen in alcoholic cirrhosis and as a side effect of phenytoin therapy
- Can also occur with other fibromatoses including Peyronie’s disease, which affects the penis, and plantar fibromatosis affecting the feet (Ledderhose disease)
What is the treatmeant of duputyrens contracture ?
Mild contractors can be tolerated but
If interfering with function or affecting the PIPJ (this joint readily stiffens and cannot tolerate it) then surgery can be done
What are the surgical options for duputyrens contracture ?
Either removal of all diseased tissue (fasciectomy) or division of cords (fasciotomy).
What is trigger finger ?
Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck
What are the signs/symptoms of trigger finger?
- Movement of the finger produces a clicking sensation, as this nodule catches on and then passes underneath the pulley.
- This can produce pain
- Finger may lock in a flexed position as the nodule passes under the pulley but can’t go back though on extension
Which fingers are msot commonly affected by trigger finger ?
Middle and ring finger
What is the treatment of trigger finger ?
1st line - NSAIDs and steroid injection
OA commonly affects the hands and wrists - what are the signs/symptoms seen ?
- DIPs will become painful, swollen and tender eventually affecting all fingers. Stiffness and bony thickening can be seen readily on examination (Heberden’s nodes). An associated dorsal ganglion cyst (known as a mucous cyst) may be present.
- PIPs can also be affected with OA and bony swelling (Bouchard’s nodes)
What is the treatment of OA of the hands and wrists ?
Mild to moderate OA may be treated with removal of osteophytes and excision of any mucous cyst.
For severe pain arthrodesis may be performed.
What is the amin difference between OA and RA affecting the hands and wrists ?
RA spares the DIPs
What are the main different deformities shown in the hands in patients with RA?
- Volar MCPJ subluxation
- Ulnar deviation
- Swan neck deformity (hyperextension at PIPJ with flesion DIPJ)
- Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)
- Z-shaped thumb
What is the 3 main stages of RA in the hands ?
- Synovitis and tenosynovitis – inflammation within the joints and the tendon sheath lead to swelling and pain in the affected structures.
- Erosions of the joints – inflammatory pannus denudes the joints of articular cartilage
- Joint instability and tendon rupture – following the progressive destruction of the bony and soft tissue structure in the hand patients can progress to subluxation and chronic tenosynovitis predisposes to extensor tendon ruptures.
The mainstay of systemic RA treatment is DMARDs but what is the treatment of the hand complications seen in RA?
- Tenosynovectomy (excision of synovial tendon sheath) may prevent not repair tendon rupture
- If tendon rupture then Tendon transfers or joint fusions
- Soft tissue releases (lengthening) may be required for contractures
- MCP replacements, PIP replacements or fusions, wrist replacement or fusion may be required for severe arthritic change.
What is a ganglion cyst ?
Mucinous filled cysts found adjacent to a tendon or synovial joint
Where are ganglion cysts commonly found ?
- The hand (DIPJ) and wrist
- Foot and ankle
- Knee (bakers cyst)
What symptoms can a ganglion cyst cause ?
Localised irritation and discomfort (may not though)
What is the clinical feel/appearance of a ganglion cyst ?
Firm, smooth and rubbery and should transilluminate
What is the treatment of ganglion cysts ?