Dupuytren's Disease and Stenosing Tenosynovitis Flashcards
What is dupuytren’s disease
A fibroproliferative disorder of the palmar and digital fascia
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 #
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
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
What is the epidemiology of dupuytrens
- Male 9:1
- RIght hand
- D4 >D5>3>2>1
- age onset 50-65yo
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
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
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
*
What disease structure causes MCP and PIP jt contractures?
MCP
- pretendinous cord
PIP
- Spiral cord (grayson, LDS, spiral band precursors)
- Lateral cord
What structures are typically uninvolved in dupuytrens
- clelands ligaments
- superficial transverse ligament
- deep trasnverse ligament
- ORL
What is you differential DDx of dupuytrens
- posttrauma joint stiffness
- diabetic fascial thikening
- traumatic palmar fasciitis
- tumor
- callus
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
What are complications of dupuytrens surgical excision
- hematoma, flap necrosis, infection
- nerve/arterial injury
- stiffness
- scars
- delayed wounds healing
- incompletion correction
- recurrence
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
What are disease associated with Stenosing tenosynovitis
- CTS
- DeQuervains
What are causes of secondary trigger thumb
- Inflammatory: DM, Gout, RA, renal D
- Metabolic: hypothyroid
- SOL: schwanomma, amyloidoisis
What is your differetnial for trigger thumb
- Metabolic
- tendinous xanthoma
- Gout, pseudogout
- MPS
- Arthritis
- RA
- hemochromatosis
- Neoplasm
- lipoma
- GCT
- fibroma intratendinous
What is the classification for trigger finger
- Pretriggering- tender catching, cant demonstrate
- Active - catching, can actively extend
- Passive - A -requires passive extension B- cant flex
- Contracture - fixed
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
What is dequervains
stenosing tenosynovitis of 1st dorsal compartment
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
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
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
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
