CASE 144
By: Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 49-year-old male with hand contractures.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
The palmar aspect demonstrates heterogeneous areas above the second flexor tendon measuring 2.3 x 0.4 x 1 cm with a synovial cyst measuring 2 x 4 x 4 mm. Furthermore, thickening of the palmar aponeurosis over the third tendon measuring 3 x 0.6 x 2.6 cm. In addition, thickening of the aponeurosis over the fourth digit flexor tendon measuring 2.5 x 0.5 x 2.6 cm. Additionally the 5th flexor tendon demonstrates thickening of the aponeurosis measuring 2.6 x 0.7 x 1.1 cm.
The tendons underneath the aponeurosis move freely with no evidence of triggering.
DIFFERENTIAL DIAGNOSIS:
· Congenital contractions, such as arthrogryposis or cerebral palsy.
· Acquired contractures such as Folkman’s contractions. Trigger finger could also give a similar appearance to the non-expert.
ASSOCIATIONS:
Disease could be associated with diabetes mellitus, alcoholism, plantar fibromatosis, Pieroni’s disease, and alcoholism.
DIAGNOSIS:
Findings of nodular thickening of the palmar aponeurosis between the skin and flexor tendons is consistent with Dupuytren’s contractures.
PEARLS AND DISCUSSION:
Dupuytren’s contractures is a progressive condition that causes shortening and thickening of the fibrous tissue of the palmar fascia. 50% could be bilateral. Involvement of the fourth ray is typical.
It typically involves people of Scotland, Iceland, Norway and Australia. It is rarely seen other area’s and is seen more commonly in male patients in their 40s to 60’s.
On ultrasound looks as marginated hypoechoic nodules in the subcutaneous tissue superficial to the flexor tendons are seen. MRI is rarely needed however if done which show nodules that are uniformly low signal intensity on T1 and T2-weighted images sequences.
If there is functional impairment and treatment with triamcinolone fluoroscopic or US guided injection could be done. Furthermore, vitamin E, gamma interferon and splinting are considered treatments. Surgery for the release of the palmar fascia is only indicated if there is functional disability or neurovascular deficit.
FURTHER READING:
1. Créteur V, Madani A, Gosset N. [Ultrasound imaging of Dupuytren's contracture]. J Radiol. 2010;91 (6): 687-91.
2. Teh J, Whiteley G. MRI of soft tissue masses of the hand and wrist. Br J Radiol. 2007;80 (949): 47-63. Br J Radiol (full text) - doi:10.1259/bjr/53596176
inauer PA, Brixey CJ, Moncur JT et-al. Pathologic and MR imaging features of benign fibrous soft-tissue tumors in adults. Radiographics. 2007;27 (1): 173-87. doi:10.1148/rg.271065065
