Dupuytren's, other fibrous or stenosing hand, hand tumors! Flashcards Preview

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Flashcards in Dupuytren's, other fibrous or stenosing hand, hand tumors! Deck (38):
1

Define Dupuytren's disease

  • Benign fibroproliferative disorder of superficial palmar and digital fascia +/- dermis

2

Describe etiology of Dupuytren's disease

  • Combinatin of genetic, environment factors and altered connective tissue formation / cytokines
  • Genetic:
    • AD with variable penetrance
    • strong association to HLA-DR3
    • "Northern European / Celtic" (or just plain European) > 80%
    • M>F 9:1
  • Environmental - controversial RFs
    • repetitive work (RR 5.5), DM, ETOH, smoking, (epilepsy, HIV, cancer)
  • Altered connective tissue
    • b-FGF - increased myofibroblast, endothelial c
    • TGF-b - increased mesenchymal cells and myofibroblast, deposition of ECM
    • PDGF - increased myofibroblast, protein (type III coll) deposition
    • Free radicals - xanthine oxidase, hypoxanthine

3

Describe natural history of Dupuytren's disease

Described by Luck (similar to 3 phases of wound healing)

  1. Proliferative - nodule formation; cellular phase, myofibroblasts, type III collagen
  2. Involution - cord formation; laying longitudinal bands of collagen, less cellularity and more organization
  3. Resolution - mature cord w/ contracture; hypocelllarity with organized collagen (type III)

4

Describe theories of pathogenesis for Dupuytren's

4 theories

  • Intrinsic - cords arise from normal tissues, and follow predictable routes of development
  • Extrinsic - nodules arise de novo superficial to normal palmar structures
  • Synthesis - combination of intrinsic and extrinsic, nodules and cords are different forms/subtypes of same disease
  • Murrell's hypothesis of positive feedback: microvessel narrowing - local ischemia - free radicals - myofibroblast - cord and contracture - more narrowing

5

What is the differential diagnosis for Dupuytren's disease

  • traumatic palmar fascitis
  • DM fascial thickening
  • Callous
  • Camptodactyly
  • Arthritis
  • Tumour
  • post-traumatic scar and joint stiffness

6

What is dupuytren's diathesis

More severe form of disease characterized by:

  • Bilateral, radial sided involvement
  • Family history
  • in men
  • earlier age of diagnosis (< 50)
  • with ectopic sites: Garrod knuckle pads, Lederhosen plantar involvement, Peyronie's penile involvement

7

Discuss anatomic origin, diseased structure and clinical significance of anatomy and pathoanatomy in Dupuytren's disease

Palm

  • Pretendinous cord - from pre-tendinous band - causes MCP flexion
  • Vertical cord - from Bands of Legue and Juvura - can cause painful triggering, tethering

Palmo-digital

  • Spiral cord - from pre-tendinous band, spiral band, natatory ligament, Grayson's ligament - MCP flexion, can displace NV bundle central, proximal, superficial
  • Natatory cord - from natatory ligament - adduction contracture

Digit

  • Central cord - digital extension of pre-tendinous cord (no normal anatomic origin) - PIPJ contracture
  • Retrovascular cord (from retrovascular band) and lateral digital cord (from lateral digital sheet) PIPJ +/- DIPJ contracture
  • ADM cord - from ADM tendon - D5 PIPJ contracure

Thumb

  • proximal and distal commissural cord - from proximal and distal commissural ligament - web contracture

8

What structures are usually uninvolved in Dupuytren's?

  • superficial transverse fibres
  • Cleland's ligament
  • deep transverse ligament
  • Oblique retinacular ligament / Landsmeer's ligament

9

List treatments for Dupuytren's disease

 

  • Non surgical modalities are largely ineffective
  • Collagenase histolyticum - Xiaflex
  • Needle aponeurotomy
  • Open fasciotomy
  • Open partial fasciectomy
  • Dermatofascietcomy with skin grafting
  • Radical fasciectomy
  • Amputation

10

  • Discuss the indication, proportion success, risk of recurrence, advantages, disadvantages and complications of needle aponeurotomy

  • Ideal for palmar pretendinous cord that is discrete (ie for MCPJ contracture)
  • Success ~ 50-55% < 5' contracture
  • Recurrence is ~ 60% at 3 yrs and 85% at 5 yrs, but studies do show variable recurrence
  • Risks: tendon laceration, digital nerve laceration, skin laceration and delayed wound healing
  • Advantages: quick, easy, symptom relief, low morbidity, multiple cords at once
  • Disadvantages: (ealry) recurrence, difficult to teach and observe

 

11

Discuss the indication, proportion success, risk of recurrence, advantages, disadvantages and complications of collagenase injection for Dupuytren's

  • Indications: best for discrete cords in palm and proximal finger; MCP & PIP contracture > 20'
  • Sucess: ~ 65% will have < 5' flexion contracture
  • Recurrence: ~ 35% at 3 years
  • Risks: bruising, swelling, lymphadenopathy, tendon or pulley rupture, CRPS
  • Advantages: less early recurrence, minimal morbidity, reasonable success
  • Disadvantages: increased risk recurrence vs. open, cost, availability

12

Discuss the indication, proportion success, risk of recurrence, advantages, disadvantages and complications of open partial fasciectomy for Dupuytren's

  • Indications: limited function, difficulty w/ hygeien, MPC > 30', PIP any, + table top, rapid progression; may be better for recurrence, revision, diffuse disease
  • Risks: classic triad (hematoma, infection, flap necrosis), tendon injury, digital nerve/arterial injury, recurrence, scar, stiffness/pain
  • Success: > 90% < 5'; recurrence: 5% @ 5 yrs (variable in literature)
  • Advantages: least recurrence, easiest to teach/observe, currently thought to be safer modality for re-do
  • Disadvantages: greatest morbidity

13

Define stenosing tenosynovitis

Tendon impingement of digital flexors as they pass through narrowed pulley and sheath; greatest impingement as flexors cross over MCP head and through A1 pulley

14

Discuss pathophysiology of trigger finger

  • Overall - size mismatch between tendon and sheath
  • Tendon - impaired nutrition / vascularity - tendon degeneration / fibrous proliferation
  • Sheath - repeated use, friction, edema, fibrocartilaginous metaplasia

15

What are the important features when counselling regarding dupuytren's

  • clinically benign
  • high recurrence and/or new disease progression
  • no cure or prevention
  • high treatment complications (espeically with open surgery)
  • significant rsk

16

Describe technique of xiaflex

 

  • 0.58ml per injection - 0.25 for MCP (palmar cord) and 0.20ml for digital
  • alcohol skin prep
  • inject direct into cord (can do passive dipj flxn to confirm not in tendon)
  • 1/3 at entry, 1/3 distal and 1/3 proximal
  • avoid > 4mm distal from proximal digital flexion crease
  • direct manipulation 24 hrs later
  • max 3 injections per digit
  • splint x 4 mos

17

Describe management of PIPJ contracture

  • pre-op stretching (using "Digit Widget") with/without joint release show mean 55' improvement compared with operative alone - mean 28'; level III (Davidson JHS european; reviewed in PRS EBM Dupuytren's 2014)
  • vs. operative joint release - steps:
    • check rein ligament release anterolateral proximal volar plate
    • accessory ligaments
    • gentle manipulation
    • +/- K-wire

18

Classify stenosing tenosynovitis

  • Congenital
  • Acquired - primary; female, single digit involvement
  • Acquired - secondary; higher multiple digit involvement
    • inflammatory - DM, RA, gout, renal disease
    • space occupying lesion

or classify by severity

  • I: pre-triggering - patient report but not observed
  • II: reproducible triggering, no locking
  • III: locks but manually reduces (or inability to completely flex)
  • IV: cannot manually reduce

19

What is the differential diagnosis of trigger digit?

  • Remote sites of tenosynovitis: A2, A3, A4 pulley, wrist (TCL)
  • Trauma: partial tendon lac
  • Infection: TB, fungi, N.gonorrhea
  • Metabolic: DM (collagen deposits), crystal arthropathy, renal (Ca oxalate crystals), hypercholesterolemia (tendinous xanthoma)
  • Neoplastic: space occupying lesion: fibroma, lipoma, GCT, cartilaginous / bony tumour

20

List and describe treatment options for acquired stenosing tenosynovitis

  • Non operative:
    • rest, splinting, NSAIDS - reasonable to start here for patients with grade I/II +/- III
    • corticosteroid injection at A1 pulley
      • varied response rates
      • ~ 50% response; Shubert Hand 2013 80% success
      • use K-10 (0.5cc; preferred) or K-40; max 2-3 injections
  • Operative
    • open A1 pulley release (only option for congenital thumb)
      • note: if trigger at A2 then increase size of A2 with slip FDS or oblique/step-lengthen of pulley
      • Kerrigan, JHS, 2011: cost effective protocol is 2 steroid injections followed by surgery
    • percutaneous release
    • complications: digital nerv einjury, tendon injury, incompelte release, bowstringing

21

Define de quervain's disease

  • stenosing tenosynovitis of 1st dorsal extensor compartment
  • (apl and epb at radial styloid)

22

discuss surgical anatomy relevent at 1st dorsal compartment when considering management of de quervain's

  • The 1st dorsal compartment is divided into subcompartments between APL and EPB in 20-30% (EPB in "sub-compartment")
  • APL has multiple slips in a proportion of patients
  • Radial sensory branch crosses over radial wrist at styloid - possibly several branches
  • Radial artery passes from volar to dorsal at this level deep to tendons

23

Describe pertinent findings on history and physical exam

  • History: middle-aged female, repeated/sustained hand stress, pregnancy/lactation (non-op mngmt successful)
  • Physical: tender & swelling at radial styloid / 1st DC, crepitus/snapping of tendons, +ve finklestein
    • can isolate EPB from APL:  by fixing thumb metacarpal in maximal abduction (eliminating APL motion) & flexing MCP to test EPB

24

Describe differential diagnosis and differentiating etiology and clinical findings

  • 1st CMC OA: joint OA - +ve grind, +ve axial load and distraction, + joint tenderness
  • Wartenberg syndrome (neuropathy of sensory branch radial nerve as it emerges from between BR & ECRB) - paresthesia sensory distribution, tinel, finklestein aggravates, radial/ulnar deviation aggravates
  • Intersection syndrome (tenosynovitis of 2nd dorsal compartment - where APL and EPB cross ECRL & ECRB about 4cm proximal to wrist)

25

describe treatment of de quervain's

  • rest, thumb spika splinting, NSAIDS - 1st line in nearly all pts
  • corticosteroid
    • 2-3 times
    • 0.5cc of k-10 (or k-40)
    • risks: moderate risk of atrophy/depigmentation, tenderness, tendon rupture
  • operative release
    • chevron 1cm proximal to radial styloid
    • identify and protect sensory branches
    • incise the 1st dorsal compartment (brent graham does a step-lengthen)
    • ensure to examine for subcompartments (higher proportion of sub compartment among patients who go on to require operative rleease)
    • risks: nerve injury, subluxation, tendon injury, scar, incomplete release

26

what is intersection syndrome?

  • Tenosynovitis of 2nd dorsal compartment
  • Pain & swelling at intersection of radial wrist extensors (ECRB, ECRL) as 1st compartment tendons cross over (APL, EPB), approximately 4 cm proximal to the wrist
  • Associated with repetitive activity (eg. athletes)
  • Treatment
  • Rest, splinting, NSAIDs, local steroid injections
  • Persistent pain ® operative release of 2nd dorsal compartment via longitudinal incision
  • Post-op: splint wrist in neutral/slight extension x 10 days

27

what is EPL tenosynovitis / tendonitis

  • Pain and swelling just distal to lister's tubercle
  • Associated with RA, OA, sequela of Colles’ fracture
  • Rarely associated with overuse
  • Treatment
  • EPL prone to rupture (eg. RA) ® early operative release of 3rd dorsal compartment
  • Subcutaneous transposition of EPL tendon radial to tubercle

28

What is FCR tenosynovitis?

  • Pain & tenderness over FCR tunnel (area of scaphoid tubercle, trapezoid crest), worse with resisted wrist flexion & radial deviation
  • Treatment:
  • Rest, splinting, NSAIDs, local steroid injections
  • Operative release of FCR tunnel for persistent pain (avoid injury to palmar cutaneous branch of median nerve)

29

List top 5 benign hand tumours

  1. Ganglion Cyst
    1. a) dorsal wrist b) volar wrist c) flexor sheath (palm) d) DIPJ (mucous cyst) e) MC boss
  2. Giant cell tumour, flexor sheath
  3. Epidermal inclusion cyst
  4. Glomus tumour
  5. Lipoma

30

what are the top malignant tumours in the hand

bcc & scc

31

what are the top malignant BONE tumours in the hand

  • chrondrosarcoma
  • osteosarcoma
  • ewing sarcoma

32

list top tumours in hand by location

  • DIPJ
    • mucous cyst, Heberden’s node 
  • PIPJ
    • Garrods knuckle pad, Bouchard nodule
  • Digit
    • GCT flexor sheath, ganglion cyst flexor sheath, inclusion cyst
  • Palm
    • Dupuytren’s cord / nodule, inclusion cyst, lipoma, GCT flexor sheath, ganglion
  • Wrist
    • Ganglion, schwannoma, neurofibroma, lipoma

33

list benign and malignant skin tumours on upper extremity

  • Benign
    • Verucca
    • Benign pigmented lesions like nevus, freckle, lentigines
    • FB granuloma
    • inclusion cyst
    • garrod pad, rheum nodules
    • Heberden and Bouchard nodules
  • Malignant
    • BCC
    • SCC
    • melanoma
    • Merkel cell

34

list benign and malignant tumours of fat in upper extremity

  • Benign: lipoma, angiolipoma
  • Malignant: liposarcoma

35

List benign and maligant hand tumours of fibrous tissue

  • Benign:
    • GCT of tendon sheat
    • Dermatofibroma (bening fibrous histiocytoma)
    • Fibroma
    • Dupuytren's (nodule)
    • Nodular fasciitis
  • Malignant
    • Malignant fibrous histiocytoma
    • DFSP

36

List benign and malignant nerve tumours of upper extremity

  • Benign: schwannoma, neurofibroma, neuroma
    • benign non-neural intraneural tumours: hemangioma, lipoma
  • Malignant: malignant peripheral nerve sheath tumour

37

List benign and malignant vascular tumours of upper extremity

 

benign

  • Hemangioma
  • Vascular malformation - most common venous)
  • Pyogenic granuloma
  • Glomus tumour
  • Aneurysm
  • Fistula

Maligant

  • angiosarcoma

38

list benign and malignant cartilage & bone tumours of upper extremity

  • Benign bone: osteoid osteoma, osteoma, exostosis; cyst: unicameral, aneurysmal; GCT of bone
  • Malignant bone: osteosarcoma, ewing sarcoma
  • Benign cartilage: enchondroma, osteochrondroma, BPOP (benign perosteal osteochromatous proliferation), periosteal chondroma
  • Malignant cartilage: chrondosarcoma