INFO - On pseudo-Dupuytren's

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University College London

" Notes on Rheumatology 2000 "

A core curriculum undergraduate rheumatology text

Compiled by Jo , MD

[one of the B-cell depletion pioneers]

http://www.ucl.ac.uk/~regfjxe/Studentinfo2.htm

Excerpt from the " Problems at Specific Sites " section:

Body of the hand and wrist

Pain in the first carpometacarpal joint (thumb base) due to cartilage wear

and osteophytes is common in middle aged women, less so in men. There is

squaring of the contour and may be progressive loss of abduction of the

thumb and wasting of the thenar eminence. Pain can be disabling initially,

making undoing jars and knitting impossible, but usually settles after a

year or two. Soft swelling or redness at the first CMC joint suggests more

than mechanical synovitis. Radiographs will help identify calcinosis or

erosive arthropathy.

Dupuytren's contracture presents as fixed flexion of fourth or other fingers

associated with fibrous contracture of the palmar fascia. A very similar

" pseudo-Dupuytren's " may occur with chronic tenosynovitis in rheumatoid

arthritis with skin puckering. Flexor tendon nodules present as trigger

finger. They occur in isolation or as part of widespread synovitis. Sudden

flexor tendon sheath swelling as a sporting injury may indicate haematoma.

Carpal tunnel syndrome is the effect of median nerve compression at the

wrist. Compression may be due to synovitis, osteochondral swelling, or other

tissue swelling as in hypothyroidism, pregnancy, or acromegaly.

Paraesthesiae in a median distribution are associated with a bursting

feeling at night relieved by hanging the hand down or shaking it. Visible

flexor sheath swelling at the wrist usually occurs as part of rheumatoid

arthritis and may be the presenting site.

Signs of median nerve damage (sensory deficit or weakness) indicate the

urgency of surgery. Immediate treatment with either splintage or injection

of steroid is useful whether or not surgery is envisaged. Relapse of

symptoms following up to three injections is an indication for surgical

decompression.

Dorsal tendon sheath swellings may be benign fibrous synovial pockets with a

gelatinous content and an acellular wall known as " ganglia " , or may be part

of a widespread inflammatory arthropathy. They require investigation and

follow up if there is any suggestion of systemic abnormality. Isolated

swelling of the tendon sheath of abductor pollicis longus and extensor

pollicis brevis (De Quervain's tenosynovitis), is nearly always an acute

overuse problem, and does not require follow up. Extensor tendon nodules

occur in lupus (small, firm and associated with arthralgia) and as

xanthomata (cholesterol), tendon rupture and dropped fingers. Small isolated

cystic synovial swellings close to the insertion of flexor carpi radialis

are quite common. They may cause persistent discomfort and may be difficult

to palpate directly. Ultrasonography is useful in defining their nature and

extent.

Aseptic necrosis of the lunate (Kienbock's disease) presents as pain in the

carpus and wrist stiffness.

Palmar erythema occurs with rheumatoid arthritis, usually when there is

constitutional disturbance. It may indicate that major remission is

unlikely.

At presentation radiographs are useful in showing fractures and the degree

of cartilage wear and bone overgrowth in mechanical joint disease but rarely

show anything useful in inflammatory arthritis at the time of presentation,

where the diagnosis remains clinical. Radiography may be helpful in

distinguishing established rheumatoid arthritis from erosive

osteoarthropathy. Serial radiographs will show progression of destructive

changes with synovitis but monitoring of joint damage clinically is probably

just as effective.

Useful procedures for the hand and wrist: Provision of a wrist splint to aid

work or provide rest at night can be useful for several wrist and thumb base

problems including carpal tunnel syndrome. Carpal tunnel syndrome often

prevents sleep and immediate relief can be obtained by injection which has

been shown to produce both clinical and electrophysiological benefit.

Persistent or recurrent symptoms will require surgical decompression in a

minority of cases. Most small hand joints and tendon sheaths can usefully be

injected for local synovitis using a 25 or 26 gauge needle. Resection of the

distal ulna and wrist synovectomy may be beneficial for persistent wrist

synovitis with pain when there is still useful movement. Tendon repairs and

transfers can restore function after tendon rupture, but should be done as

soon as possible. Wrist arthrodesis is indicated for persistent pain in a

damaged wrist when movement is already severely limited.

http://www.ucl.ac.uk/~regfjxe/PROBLEMS.htm

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Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org