Dupuytren's Disease and Stenosing Tenosynovitis Flashcards Preview

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Flashcards in Dupuytren's Disease and Stenosing Tenosynovitis Deck (24):
1

What is dupuytren's disease

A fibroproliferative disorder of the palmar and digital fascia

2

What are the 3 stages of dupuytrens disease

  • Proliferative: increase in myofibroblasts
  • Involutional: increase in immature collagen type 3 deposition
  • Residual: contraction of cords, drop in cell #

3

What are the theories of dupuytrens disease development

  • Intrinsic - disease develops from existing normal anatomic structures
  • Extrinsic - disease develop from abnormal nodules
  • Synthesis - disease develops from both de novo abnormal tissue (nodule) and normal anatomy (bands to cords)
  • Murrell's hypothesis - microvascualr narrowing leads to ischemia, ROS and secondary proliferation/stimulation of myofibroblasts which worsens perfusion and cyclical proliferation

4

What are risk factors for developng Dupuytrens'

  • Family Hx (autosomal dominant inheritance)
  • HLA-DR3 mutation
  • Ethnicity (Celtic, northern european)

Controversial Rfs

  • repetitive work (vibration)
  • HIV
  • Cancer
  • DM (radial digits more likely affected)
  • antiepileptics

5

What is the epidemiology of dupuytrens

  • Male 9:1
  • RIght hand
  • D4 >D5>3>2>1
  • age onset 50-65yo

6

What are risk factors for high reucrrence or indicators of severe disease

  • Onset <50yo
  • bilateral disease, radial digits
  • Ectopic disease (garrods nodes PIP, peyronies, Lederhosen)
  • Family History

7

Describe the normal anatomical components of the palmar and digital fascia

PALM

  • Pretendinous band
  • Transverse fibers
  • Natatory ligaments

 

PALM-DIGIT JUNCTION

Pretendinous band diverge to 

  • Spiral band
  • Flexor sheath bands (Lejeu and Juvara)
  • Skin

 

DIGIT

  • Lateral digital sheet (coalescnce of natatory/spiral band)
  • Grayson's lig
  • Cleland's lig
  • Retrovascular bundle

8

Describe the diseased anaotmic structures and their precursor

PALM

  • Pretendinous Cord (PT band) =>MCP contracture

PALM_DIGIT JUNCTION

  • Spiral cord
  • Natatory cord

DIGIT

  • Central cord
  • Lateral cord
  • Spiral cord
  • Retrovascular cord
  • knuckle pads
  •  

9

What disease structure causes MCP and PIP jt contractures?

MCP

  • pretendinous cord

PIP

  • Spiral cord (grayson, LDS, spiral band precursors)
  • Lateral cord

10

What structures are typically uninvolved in dupuytrens

  • clelands ligaments
  • superficial transverse ligament
  • deep trasnverse ligament
  • ORL

11

What is you differential DDx of dupuytrens

  • posttrauma joint stiffness
  • diabetic fascial thikening
  • traumatic palmar fasciitis
  • tumor
  • callus

12

What are treatment options for dupuytrens

NON-OP

  • splints
  • XIAFLEX - clostridrium histolyticum collagenase
  • Percutaneous needle aponeurotomy

OPERATIVE

  • Surgical excision
    • Fasciotomy
    • Limited fasciectomy
    • Dermatofasciectomy
    • Radical fasciectomy

 

13

What are complications of dupuytrens surgical excision

  • hematoma, flap necrosis, infection
  • nerve/arterial injury
  • stiffness
  • scars
  • delayed wounds healing
  • incompletion correction
  • recurrence

14

What is steonsing tenosynovitis

Mismatch between tenson size and sheath causing mechanical impingement of flexor tendon

 

Etiology

?tendon thickening 2' ischemia

  • sheath hypertrophy 2' to trauma/repetitive injury causing increase collagentype 3 and chondrocytes

15

What are disease associated with Stenosing tenosynovitis

  • CTS
  • DeQuervains

16

What are causes of secondary trigger thumb

  • Inflammatory: DM, Gout, RA, renal D
  • Metabolic: hypothyroid
  • SOL: schwanomma, amyloidoisis

17

What is your differetnial for trigger thumb

  • Metabolic
    • tendinous xanthoma
    • Gout, pseudogout
    • MPS
  • Arthritis
    • RA
    • hemochromatosis
  • Neoplasm
    • lipoma
    • GCT
    • fibroma intratendinous

18

What is the classification for trigger finger

  1. Pretriggering- tender catching, cant demonstrate
  2. Active - catching, can actively extend
  3. Passive - A -requires passive extension B- cant flex
  4. Contracture - fixed

19

What are treatment options

NON-op

  • NSAIDs, splint, rest, discontinue repetitive activity
  • Steroid into tendon sheath (80% success) - try 2 then operative (failed conservative)

Operative

  • Surgical release
    • if failed ocnservative management

20

What is dequervains

stenosing tenosynovitis of 1st dorsal compartment

 

21

What are signs and symptoms of Dq

Symptoms

  • radial sided wirst pain 
  • worse w repetitive activities
  • onset in lactation and pregnancy

 

Signs

  • positive finkelsteins
  • swelling at radial styloid

22

What is in your DDX for radial sided wrist pain as mimickers of DeQuervains

  • Intersection syndorme
    •  compression of 2nd compartmnet - where 1st crosess 2nd -4cm proximal to wrist crease
  • CMC arthritis
    • pain to joint and grind test +
  • Wartenberg syndrome
    • compression neuropahty of DRSN as it passess below ECRB

23

What is your treatment of Dq

Non- op - 

  • rest, thumb spica, NSAIDs, avoid repetitive activities
  • steroid - 1cm proximal to radial styloid

Operative

  • transverse/longitudinal incision 1cm proximal to wrist crease
  • protect DSRN
  • leave flap longer for volar support
  • complete release of multiple slips of APL

24

What is intersection syndrome

compression of 2nd extensor copartment by 1st compartment structures

4cm proximal to wirst crease

Non-op tx w splint NSAIDs, altered activity

op: release 2nd compartment 

A image thumb