Dupuytren's Disease and Stenosing Tenosynovitis

Question 1

What is dupuytren’s disease

Answer 1

A fibroproliferative disorder of the palmar and digital fascia

Question 2

What are the 3 stages of dupuytrens disease

Answer 2

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

Question 3

What are the theories of dupuytrens disease development

Answer 3

• 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

Question 4

What are risk factors for developng Dupuytrens’

Answer 4

• 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

Question 5

What is the epidemiology of dupuytrens

Answer 5

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

Question 6

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

Answer 6

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

Question 7

Describe the normal anatomical components of the palmar and digital fascia

Answer 7

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

Question 8

Describe the diseased anaotmic structures and their precursor

Answer 8

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
  *

Question 9

What disease structure causes MCP and PIP jt contractures?

Answer 9

MCP

• pretendinous cord

PIP

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

Question 10

What structures are typically uninvolved in dupuytrens

Answer 10

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

Question 11

What is you differential DDx of dupuytrens

Answer 11

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

Question 12

What are treatment options for dupuytrens

Answer 12

NON-OP

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

OPERATIVE

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

Question 13

What are complications of dupuytrens surgical excision

Answer 13

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

Question 14

What is steonsing tenosynovitis

Answer 14

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

Question 15

What are disease associated with Stenosing tenosynovitis

Answer 15

• CTS
• DeQuervains

Question 16

What are causes of secondary trigger thumb

Answer 16

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

Question 17

What is your differetnial for trigger thumb

Answer 17

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

Question 18

What is the classification for trigger finger

Answer 18

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

Question 19

What are treatment options

Answer 19

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

Question 20

What is dequervains

Answer 20

stenosing tenosynovitis of 1st dorsal compartment

Question 21

What are signs and symptoms of Dq

Answer 21

Symptoms

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

Signs

• positive finkelsteins
• swelling at radial styloid

Question 22

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

Answer 22

• 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

Question 23

What is your treatment of Dq

Answer 23

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

Question 24

What is intersection syndrome

Answer 24

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