Dupuytren”s Disease

Indications

Dupuytren”s disease is a condition causing localized thickening of the fascia of the palm and fingers. The fascia is a sheet of tissue lying under the palmar skin, but above the tendons which bend the fingers and above the nerves and blood vessels going to the fingers. Thickening of the fascia causes lumps in the skin (nodules); pits in the skin and in more severe disease the thickenings may bend the fingers towards the palm “Dupuytren”s contracture”.

Causes/preventions

There are several conditions that are associated with Dupuytren”s disease. However, the exact cause remains unknown. There is a tendency for Dupuytren”s disease to run in families; nearly 70% of first degree relatives of an individual with Dupuytren”s disease will also be affected. Individuals probably inherit a tendency to develop the disease, which might or might not appear depending upon the presence or absence of other factors.

Before & After
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Signs and Symptoms

People with Dupuytren”s disease may develop thickening in the palmar skin; usually this is first noticed as a nodule in, and under, the skin of the palm. There may be a small pit in the palmar skin. With progression of the condition the thickenings may develop into cord like structures which pass into the fingers. These thickenings may cause contractures (bending) of the fingers. The disease most commonly affects the ring and little finger; although any digit may be involved. The condition may affect both hands and may be associated with a similar problem in the feet and occasionally with an upward bend in the erect penis (Peyronie”s disease).

Complications of disorder

Untreated, the disease may cause gradually worsening contractures of the fingers. The rate and degree at which this occurs is varied and in some individuals does not happen. If the finger joints are left in a bent state for a long period it may never be possible to straighten them, even with appropriate treatment.

Tests

No special test are needed; a doctor can make the diagnosis based on the story given by a patient and the findings of an examination.

Treatment

Surgery is necessary for patients who are experiencing functional problems; who have disease which is progressing quickly and if disease affects the middle joint (proximal interphalangeal joint) of any finger. If the proximal interphalangeal joint of any finger is bent by Dupuytren”s disease, early surgery is usually advised, because if left in a bent position, for prolonged periods, it may be impossible to straighten at a later date. Under anaesthetic, cuts are made in the finger and palm to remove the Dupuytren”s disease (fasciectomy). Sometimes, the cord-like structures are simply cut without removal of the diseased fascia (fasciotomy). Fasciotomy has a very high recurrence rate and is usually reserved for particular situations. After surgery, a splint is usually worn continuously for one week and then at night only for up to 3 months. After the splint is removed exercises (hand therapy) are necessary to regain mobility in the hand. Hand therapy may be needed for several weeks. Any stitches are removed after 2 – 3 weeks.

Outcome

In patients with longstanding contractures, it may not be possible to fully straighten all of the involved digits; the proximal interphalangeal joint is particularly troublesome and if this joint has been affected an average residual contracture of 30° has been reported. It is not possible to cure Dupuytren”s disease by surgery. Many patients have their disease controlled such that further functional problems do not occur. However, in a percentage of people, the disease will come back in the affected digit (recurrence of disease) or will develop and involve other digits (extension of disease).

Ganglion Cysts (Ganglia)

Indications

Ganglions cysts are benign soft tissue lumps that occur in the hand and wrist. They can occur at several locations, most commonly on the back of the wrist. Less common locations include the front of the wrist, the front of the fingers and the back of the last joint of the fingers.

Signs/symptoms

Patients often complain of pain in the wrist or hand associated with ganglion cysts. The cyst itself is sometimes tender to pressure. The cyst produces a visible swelling and many patients are unhappy with the cosmetic appearance. These cysts are soft and can be squashed. The cyst is slightly mobile and light-up brightly if a small light source is placed against it.

Complications of disorder

There are no significant complications of the ganglion itself. No tests are necessary to diagnose the vast majority of ganglia. Occasionally, ganglia may lie deep in the hand or elsewhere in the upper limb. These ganglia may produce symptoms but may be difficult to diagnose. The doctor may order special scans, CT and MRI, to diagnose ganglia in these situations.

Treatment

Non-Operative:
Most ganglia require no treatment. An explanation of the condition and assurance that it is non-malignant is often the only treatment sort or required. All non-surgical methods have limited success and a significant recurrence rate. However, they are simple to perform and reduce the swelling, albeit temporarily. Non-surgical treatment involves placement of a large needle into the ganglion cyst and aspirating its contents. Some surgeons then inject the ganglion with local anaesthetic agents or steroids.

Surgical:
Surgical treatment of ganglia is best reserved for patients with persistently symptomatic lesions.

Carpal Tunnel Syndrome (Cts)

Indications

Carpal Tunnel Syndrome (CTS) is numbness, tingling pain, and weakness in the thumb, index and middle fingers as a result of irritation of the median nerve at the wrist.

Causes

The most common conditions that can lead to CTS are obesity, oral contraceptives, hypothyroidism, arthritis, diabetes, trauma and stress caused by training and pressure on the wrist. Repetitive work such as uninterrupted typing and playing the drums can cause tendon inflammation which may cause CTS. However, genetics has been cited as a larger factor in the cause of CTS.

Signs/symptoms

People with CTS initially feel numbness and tingling of the hand in the median nerve (the thumb, index, middle, and part of the fourth fingers). These sensations are often more pronounced at night and can awaken people from sleep. It may be due to the flexed-wrist sleeping position and/or fluid accumulating around the wrist and hand while lying flat.

Complications of Disorder

It can be a temporary condition that completely resolves or it can persist and progress. As the disease progresses, patients can develop a burning sensation, cramping and weakness of the hand. People with CTS may drop objects involuntarily due to decreased grip strength. Occasionally, sharp shooting pains can be felt in the forearm. Chronic carpal tunnel syndrome can also lead to atrophy of the hand muscles.

Treatment

The choice of treatment for CTS depends on the severity of the symptoms and any underlying disease that might be causing the symptoms.

Non-Operative:

Initial treatment usually includes rest, immobilization of the wrist in a splint, and occasionally ice application. Measures to prevent the symptoms of carpal tunnel have to be taken such as periodic rest and stretching exercises. Many health professionals suggest that, for best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists. People with CTS and whose occupations are aggravating the symptoms should modify their activities. Underlying conditions or diseases are treated individually. Fractures can require orthopedic management. Obese individuals will be advised regarding weight reduction. Several types of medications have been used in the treatment of carpal tunnel syndrome. Non-steroidal anti-inflammatory drugs, which should be taken with food, can also be helpful in decreasing inflammation and reducing pain. Corticosteroids can be given by mouth or injected directly into the involved wrist joint. They can bring rapid relief of the symptoms of carpal tunnel syndrome.

Surgical:
To avoid serious and permanent nerve and muscle consequences of carpal tunnel syndrome, surgical treatment is considered. Surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. This surgical procedure is called “carpal tunnel release”, which is performed with a small diameter viewing tube, called an arthroscope, or by open wrist procedure. After carpal tunnel release, patients often undergo exercise rehabilitation.