Dupuytren's Contracture
K. Gupta, P. Carmichael, A. Zumla in 100 Short Cases for the MRCP, 2020
The fibrosis and thickening of the palmar fascia and of the flexor tendons is the underlying pathology of Dupuytren's contracture. This subsequently results in the flexion deformity of the metacarpophalangeal joints, especially of the ring and the middle fingers and loss of function of the fingers. It is important to palpate the palms so that you do not miss the thickened fascia in patients with early Dupuytren's contracture. In most cases the condition becomes bilateral. Dupuytren's contracture must be distinguished from ulnar nerve palsy which is characterized by the loss of function of the dorsal and palmar interossei muscles (loss of flexion of proximal phalanx, extension of dorsal phalanx, adduction and abduction of fingers). Loss of sensation over the ulnar border of the hand is also a feature of ulnar nerve palsy (see Case 85).
Trauma and orthopaedic surgery
Philip Stather, Helen Cheshire in Cases for Surgical Finals, 2012
You are asked to see a medical inpatient, Sandra, who complains that for the last few years she has found it hard to completely extend the fingers on her right hand. On examination, you find thickened digital and palmar fascia on the hand. You also notice contractures and fixed deformities at the MCP and PIP joints of the middle and ring finger. What disease does Sandra have? (1 mark)Give five risk factors associated with this disease. (5 marks)Which finger is most commonly affected? (1 mark)Give one conservative treatment for the condition. (1 mark)Give two surgical procedures that can used to treat this condition. (2 marks)
Clinical Evaluation
J. Terrence Jose Jerome in Clinical Examination of the Hand, 2022
The superficial palmar fascia is triangular in shape and lies in the coronal plane of the palm. The apex of the triangle contains the transverse carpal ligament and terminal fibres of the palmaris longus tendon. The apex is confluent, and the base is divergent lying under the transverse retinacular ligament. There are four central bands (pretendinous bands) which originate from the apex and extend distally to each finger except the thumb. The base is wide, and all these four bands are bridged by a superficial transverse palmar ligament. This ligament continues as proximal first webspace ligament along the radial border of the index central band reaching to the radial sesamoid of the thumb MCP joint (Figure 2.21).
Extensive high-pressure injection injury of the hand due to epoxy resin paint: a case report
Published in Case Reports in Plastic Surgery and Hand Surgery, 2021
Gaku Niitsuma, Hidechika Nakashima, Takushi Nagai, Kenichirou Teramoto, Keikichi Kawasaki, Katsunori Inagaki
The mechanism of high-pressure injection injuries postulated by Kaufman states that the subcutaneously injected fluid infiltrates the loose connective tissue along the fascia [7,8]. The injected fluid progresses along the digital neurovascular bundle, passes through the lumbrical space to the dorsal side, and progresses from the carpal tunnel to the Parona’s space of the forearm [1]. In the present case, the high-pressure injection injury occurred in the center of the palm, and the injected fluid seeped through the carpal tunnel proximally. It entered two layers in the thenar region, between the palmar aponeurosis and transverse carpal ligament. Distally, it tracked to all MP joints of the fingers, along the digital neurovascular bundles. Especially in the ring finger, it penetrated the dorsal MP joint through the lumbrical space. The fluid infiltrated an extensive area proximally and distally. Therefore, we could not completely debride it (Figure 5(c)). Once the necrotic tissue was debrided thoroughly, all flexor tendons and the median nerve were exposed. The paint could thus be removed sufficiently in the third operation. The patient’s neurological symptoms and ROM of the fingers improved significantly thereafter. However, there is no clarity regarding the early response and long-term progress in such cases.
Angiotensin receptors in Dupuytren’s disease: a target for pharmacological treatment?
Published in Journal of Plastic Surgery and Hand Surgery, 2018
Christopher Stephen, Leila Touil, Partha Vaiude, Jaipaul Singh, Stuart McKirdy
Dupuytren’s disease is an acquired condition of the hand associated with progressive fibrosis and contraction of the palmar fascia, leading to loss of function and significant morbidity. Although first described in 1831, the condition is not yet fully understood. The current mainstay of treatment is surgical; however, the progressive nature of the disease means that surgery cannot be regarded as curative, and so prevention of recurrence remains a major challenge. Therefore, much interest exists in developing therapies to prevent or slow disease progression. To this end, several pharmacological agents have been trialled, including calcium channel blockers, verapamil, azathioprine, procarbazine, prostaglandin E, γ-interferon, and corticosteroids [1], without success. In the present study, we aim to explore the basis for using an anti-fibrotic agent, ACE inhibitors, in this disease.
Palmaris longus interposition in revision surgery for recurrent and persistent carpal tunnel syndrome: a case series
Published in Journal of Plastic Surgery and Hand Surgery, 2020
Pepijn Olivier Sun, Maxime Victorine Pauline Schyns, Erik Taco Walbeehm
All patients underwent extended open CTR. The previous incision is always used and extended proximally with approximately 4 cm, with a break of the incision at the wrist in ulnar direction. Subsequently, the forearm fascia is opened proximally on one side of the palmaris longus (PL) tendon, depending on where the previous incision was placed. The median nerve is released in the forearm (if necessary), and only when the nerve is seen, the dissection is continued distally. Next, the palmar fascia is incised, again depending on the previous incision and the flexor retinaculum can then be easily transected again, from proximal to distal (Figure 1). The release should be completed distally. Subsequently, the PL tendon is released from its compartment in the forearm fascia, leaving the epitenon around the tendon intact. The tendon is transected sufficiently proximal to reach the end of the carpal tunnel when flipped distally (Figure 2). The tendon is then sutured between the two edges of the flexor retinaculum with Vicryl 4-0, with three to four sutures on each side of the retinaculum (Figure 3). As this lengthens the flexor retinaculum, it should increase the volume in the carpal tunnel. Sutures are placed on the outside of the carpal tunnel to avoid contact with the median nerve. In addition, the epitenon is left in place with hope of diminishing adhesions. The skin is closed with Ethilon 4-0. A slight volar cock-up Plaster of Paris is applied directly postoperatively, and the wrist is immobilized for three weeks. Patients are referred to the hand therapists for finger exercises initially and nerve gliding and range of motion exercises following the three weeks of immobilization.
Related Knowledge Centers
- Deep Fascia
- Ulnar Nerve
- Flexor Retinaculum of The Hand
- Palmaris Longus Muscle
- Metacarpophalangeal Joint
- Lumbricals of The Hand
- Palmaris Brevis Muscle
- Superficial Palmar Arch
- Little Finger