Download Dupuytren’s Contracture

Dupuytren’s Contracture
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Dupuytren’s Contracture
 Fibrous tissue of the palmar fascia to
shorten and thicken
 Common in men older than 40 years; in
persons of Northern European descent; and
in persons who smoke, use alcohol, or have
diabetes (3 to 33 %)
 Present with a small, pitted nodule (or
multiple nodules) on the palm, which slowly
progresses to contracture of the fingers
 Progresses' faster in <50 yr olds
 Smoking and alcohol use increase the
chance that surgery will be needed
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Dupuytren’s
Contracture
 Found on the palm of the
hand proximal to the
metacarpo-phalangeal
 Grade 1 disease presents
(MCP) joint. Can be
as a thickened nodule
bilateral
and a band in the palmar
aponeurosis; this band
 Patients usually have
may progress to skin
difficulty with tasks such
tethering, puckering, or
as face washing, hair
pitting.
combing, and putting
their hands in their
 Grade 2 presents as a
pockets.
peritendinous band, and
extension of the affected
 Note the site of the
finger is limited.
nodule and the presence
of contractures; bands;
 Grade 3 presents as
and skin pitting,
flexion contracture
tenderness, and dimpling.
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Fibromyalgia
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 Characteristic features:
 Chronic widespread pain for at least
three monthsTender points in 11 of 18
specific anatomic locations
 Associated features
 Anxiety
 Cognitive difficulties
 Fatigue
 Headache (50%) (migraine)*
 Paresthesias, morniing stiffness
 Sleep disturbance
*?a defect in the serotonergic and
adrenergic systems
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Associated Findings
 History of trauma,

childhood abuse, anxiety,
depression, or sleep

disorder (alpha frequency
rhythm, termed alpha-delta 

sleep anomaly )

 Patients with high tender
point counts are more likely 
to report adverse childhood
experiences like loss of a

parent or abuse

 Irritable bowel syndrome
(IBS)
Other disorders commonly
associated with FM include:
Irritable bladder
Dysmenorrhea
Premenstrual syndrome
Restless leg syndrome
Temporomandibular joint
pain
Noncardiac chest pain
Raynaud's phenomenon
and Sicca syndrome
(Sjogren’s)
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Other
Diagnoses/Associated
 Myofascial pain syndrome,
 Chronic fatigue syndrome, and
 Hypothyroidism.
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Myofascial pain syndrome
 Characterized by painful, tender areas in
the muscles.
 It is a localized disorder without any
systemic manifestations.
 It commonly affects the axial muscles.
 In contrast to the widespread pain of
fibromyalgia, the pain in myofascial pain
syndrome arises from trigger points in
individual muscles.
 On examination, the presence of trigger
points is characteristic of myofascial pain
syndrome.
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Chronic fatigue syndrome
(CFS)
 Chronic pain and fatigue are common to
chronic fatigue syndrome and fibromyalgia.
 CFS an ongoing subclinical inflammatory
process manifested by low-grade fever,
lymph gland enlargement, and acute onset
of the illness, whereas there is no evidence
of inflammatory response in fibromyalgia.
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Hypothyroidism
 Manifested by profound fatigue, muscle
weakness, and generalized malaise, closely
resembles fibromyalgia.
 Patients need to be examined for clinical signs
of thyroid dysfunction and, if in doubt, thyroid
function tests should be ordered to rule out
hypothyroidism.
 (The differential diagnosis also might include
metabolic and inflammatory myopathies
(especially in patients taking statins),
polymyalgia rheumatica, and other rheumatic
diseases. )
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 optimal intervention is an approach that
also includes nonpharmacologic treatments,
specifically exercise and cognitive behavior
therapy
 education, cognitive behavior strategies,
physical training, and medications for
treatment of fibromyalgia
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FIBROMYALGIA-Review
Multi symptom
condition
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Multi symptom condition
characterized by chronic widespread
pain
Muscular pain
Fatigue
Sleep abnormalities
Joint pain
Headaches
Restless legs
Numbness
Impaired memory
Leg cramps
Impaired
concentration
Nervousness
Major depression
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Patient-Reported Symptoms at
Diagnosis of Fibromyalgia
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Features
3 months or longer in all 4 quadrants of the body,
but not centered in the joints
Lower pain threshold:
Allodynia-pain from normally non noxious stimuli
Hyperalgesia-increased response to painful stimuli
Under diagnosed and undertreated
(Prevalence:2% to 4%)/
Onset usually at 20 to 55 years/ F:M 9:1
First-degree relatives of FM patients have 8 times
the risk
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?etiology
Pain amplification
Lower levels of metabolites of serotonin and
norepinephrine in their cerebrospinal fluid
Increased levels of pro-nociceptive
transmitters substance P and glutamate that
amplify pain impulses
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No objective laboratory test or marker
exists, diagnosis is based on history and
physical examination
Chronic Widespread Pain for at least 3
months and pain on at least 11 of 18
specified muscle tendon sites of focal
tenderness (“tender points” 11/18)
Use of a structured interview with questions
about generalized fatigue, headache, sleep
disturbance, neuropsychiatric complaints,
numbness or tingling, and irritable bowel
symptoms.
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POINTS OF TENDERNESS
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?TREATMENT Eval Criteria
SYMPTOM
CRITICAL FOR EVAL%
Pain
100
Fatigue
94
Patient global
improvement
94
Multidimensional function
86
Tenderness
74
Sleep
66
Health-related quality of life
65
Dyscognition
61
Stiffness
60
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Current Knowledge About
Pharmacotherapies
‘Off label’
SNRIs
Anticonvulsants
Tricyclic
antidepressants (TCAs)
Muscle relaxants
SSRIs
Opioids
Nonsteroidal antiinflammatory drugs
(NSAIDs) and
Cyclo-oxygenase
(COX2) inhibitors
 FDA ‘approved’
 Pregabalin(Lyrica)
 Duloxetine
Hydrochloride (Cymbalta)
 Milnacipran
Hydrochloride(Savella)
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Pregabalin
(Lyrica)
Duloxetine
Hydrochloride
(Cymbalta)
Milnacipran
Hydrochloride
(Savella)
Alpha2 receptor
SNRI
SNRI
150-225 mg bid
75 mg bid
May increase to 150 mg
bid within 1 wk
Maximum dose 225 mg
bid
60 mg/d
Start 30 mg/d for 1
wk, increase to 60
mg/d
50 mg bid (start 12.5
mg/d, increase on day 2
to 12.5 mg bid,
on day 4 to 25 mg bid,
after day 7 to 50 mg bid)
Maximum dose 200 mg/d
Angioedema,
hypersensitivity
reactions, peripheral
edema
Suicidality, orthostatic
hypotension, serotonin
syndrome
Suicidality, orthostatic
hypotension, serotonin
syndrome
Dizziness, somnolence,
dry mouth, edema,
blurred vision, weight
gain, difficulty with
concentration/attention
Nausea, dry mouth,
constipation,
somnolence,
hyperhidrosis,
decreased appetite
Nausea, headache,
constipation,
dizziness, insomnia, hot
flush, hyperhidrosis,
vomiting, palpitations,
heart rate increase, dry
mouth, hypertension
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