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Toronto Notes 2019 Hand Dupuytren’s Disease
Definition
• proliferativedisorderofthepalmarfascia,formingnodules(usuallypainless),fibrouscords,andflexion contractures at the MCP and interphalangeal joints
• flexortendonsnotinvolved
• Dupuytren’sdiathesis:malesex,earlyageofonset,strongfamilyhistory(autosomaldominant
inheritance), involvement of multiple digits, bilateral involvement, and involvement of sites other than palmar aspect of hand, including the plantar fascia (Ledderhose’s) and the penis (Peyronie’s) – (see Urology, U32)
Epidemiology
• unusualinpatientsfromAfricanandAsiancountries,highincidenceinnorthernEuropeans,men> women, often presents in 5th-7th decade of life; associated with but not caused by alcohol use, smoking, and DM
Clinical Features
• nodules,cords,andcontracturesofMCP,PIP,andDIP
• orderofdigitinvolvement(mostcommontoleastcommon):ring>little>long>thumb>index • riskofrecurrence
Treatment
• palmarpitornodule:nosurgery(steroidinjectionsforpain)
• palpableband/cordwithnolimitationofextension(i.e.nocontracture)ofeitherMCPorPIP:no
Plastic Surgery PL29
surgery
• MCPcontracture>30oorPIPcontractureofanydegree:needleaponeurotomy,collagenaseclostridium
histolyticum (Xiaflex®) injection, or surgical fasciectomy
• contracturesimpedingfunctionand/orhygiene:needleaponeurotomy,collagenaseinjection,or
surgical fasciectomy
• MCPjointshavebetteroutcomesthanPIPjointspost-treatment(achievementofnearfullextension,
lower risk of recurrence)
Carpal Tunnel Syndrome
Definition
• mediannervecompressionattheleveloftheflexorretinaculum/transversecarpalligament
Etiology
• mediannerveentrapmentatwrist
• primarycauseisidiopathic
• secondarycauses:spaceoccupyinglesions(tumours,hypertrophicsynovialtissue,fracturecallus,and
osteophytes); metabolic and physiological (pregnancy, hypothyroidism, acromegaly, and RA); job/ hobby related repetitive trauma, especially forced wrist flexion
Epidemiology
• female:male=4:1,mostcommonentrapmentneuropathy
Clinical Features
• classically,patientawakenedatnightwithnumb/painfulhand,relievedbyshaking/dangling/rubbing
• onexam,sensorylossinmediannervedistribution(seeFigure4),butthenareminencesensorylossis
spared (palmar cutaneous branch given off prior to carpal tunnel)
• decreasedlighttouchand2-pointdiscriminationatDIPradialandulnarcreases;discriminativetouch
often lost first
• advancedcases:thenarwasting/weaknessduetoinvolvementofthemotorbranchofthenerve
• ±Tinel’ssign(tinglingsensationonpercussionofnerve)
• ±Phalen’ssign(wristflexioninducessymptoms)
Investigations
• clinicaldiagnosis
• NCVandEMGstudiesmaybeusedtoobjectivelyconfirmthediagnosis
Treatment
• avoidrepetitivewristandhandmotion,wristsplintsatnightandwhenrepetitivewristmotionrequired • conservative:night-timesplintingtokeepwristinneutralposition
• medical:NSAIDs,localcorticosteroidsinjection(relieffromlocalcorticosteroidinjectionsisalso
diagnostic)
• surgicaldecompression:transversecarpalligamentincisiontodecompressmediannerve
• indicationsforsurgery:persistentsignsandsymptomsofmediannervecompressionnotrelievedby
Palmar aponeurosis
Cord Nodule
Figure 26. Dupuytren’s disease
conservative management
© Monika Musial