There is thickening and shortening of the palmar fascia and the adjacent connective tissues
These are the tissues lie
deep to - the subcutaneous tissue of the hand and
superficial to - the flexor tendons.
As the thickening increases, the fascia becomes attached to the skin of the palm.
Risk factors
No obvious predisposing cause
Cirrhosis
Repeated local trauma
Shoe repairers
Manual labourers.
Epilepsy
Age Dupuytren’s contracture usually begins in middle age, but usually progresses so slowly that most patients do not present until old age.
Symptoms
Early
There is a nodule in the palm.
The patient may notice a thickening in the tissues in the palm of the hand, near the base of the ring finger, many years before the contractures develop
Late
Contraction deformities occur.
The patient notices an inability to fully extend the metacarpophalangeal joint of the ring finger, and later the little finger.
There is usually no pain associated with this condition, but the nodule in the palm may be slightly tender.
Deep creases form where the skin becomes tethered to the fascial thickening, and the skin in these creases may get soggy and excoriated.
Multiplicity Dupuytren’s contracture is commonly bilateral and can also occur in the feet.
Risk factor
Dupuytren’s contracture may follow repeated trauma to the palm of the hand, which is probably why it used to be found in shoe repairers and other manual workers, but nowadays it is uncommon to find a convincing cause.
may be symptoms of epilepsy or cirrhosis of the liver.There is a higher incidence of the condition in patients suffering from these diseases.
If so, it is inherited in an autosomal dominant manner.
Examination
Palpation of the palm of the hand reveals a firm, irregularly shaped nodule with indistinct edges, 1–2 cm proximal to the base of the ring finger.
Taut strands can be felt running from the nodule to the sides of the base of the ring and little fingers, and proximally towards the centre of the flexor retinaculum.
The skin is puckered and creased, and tethered to the underlying nodule.
The deformity The metacarpophalangeal joint and the proximal interphalangeal joint are flexed because the palmar fascia is attached to both sides of the proximal and middle phalanges.
The distal interphalangeal joint tends to extend.The ring finger is most affected and may be pulled down so far that its nail digs into the palm of the hand (Fig.
The flexion deformity is not lessened by flexing the wrist joint.
There may be some thickening of the subcutaneous tissue on the back of the proximal phalanges of the affected fingers, sometimes called Garrod’s pads.
The patient is rarely aware of the fact that they have a deformity, accepting it as the normal shape of their little finger.
It is mentioned here because, although it is the opposite deformity to a Dupuytren’s contracture, the student who is unaware of its existence may misdiagnose it.
Someone with a congenital contracture of the little finger has this deformity all the time and cannot straighten the finger (Fig.
This is a shortening of the long flexor muscles of the forearm, caused by fibrosis of the muscles, secondary to ischaemia.
The common causes of the ischaemia are direct arterial damage at the time of a fracture near the elbow (most often a supracondylar fracture (see below), a tight plaster that restricts blood flow and arterial embolism.
Indeed, the loss of finger movements frequently begins while the arm is immobilized for the treatment of the fracture.
Symptoms When muscles become ischaemic, they are usually painful.
If a patient complains of pain under their plaster at a point distant from the site of the fracture, remove the plaster and examine the muscles carefully.
Movements of the fingers, especially extension, become painful and then limited.
The patient soon discovers that they can extend their fingers if they flex their wrist when the forearm is not in a plaster cast.
The skin of the hand will be cold and pale as the blood supply of the hand is also diminished.
Ischaemia of the nerves in the anterior compartment (the median and anterior interosseous nerves) often causes ‘pins and needles’ (paraesthesia) in the distribution of the median nerve, and sometimes the severe burning pain of ischaemic neuritis.
Development As the acute phase passes, the pain slowly fades away, but the restriction of finger extension increases, and the hand becomes claw- like.
Inspection The skin of the hand is usually pale, and the hand looks wasted.
All the finger joints are flexed, and the anterior aspect of the forearm is thin and wasted. The deformity is called a ‘claw hand’ (Fig.
Palpation In the acute phase, the forearm is swollen and tense, but once this has passed the forearm feels thin, the hand is cool and the pulses at the wrist may be absent.
In the later stages, the fibrosis and shortening make the forearm muscles hard and taut.
Movement Extension of the fingers is limited, but improves as the wrist is flexed.
Further flexion of the fingers (beyond the deformity) can occur, but the grip is weak.
Passive forced extension of the fingers is painful in the acute stage and uncomfortable in the established condition.
An important diagnostic feature of an ischaemic contracture is that all the muscles, even the damaged ones, have some function, whereas in a claw hand caused by a nerve lesion, some of the muscles are completely paralysed.
The heart, great vessels, subclavian and axillary arteries must be examined carefully in case they are the source of an arterial embolus.
Palpate the supraclavicular fossa for a cervical rib (see Chapter 9) or subclavian artery aneurysm (see Chapter 10).
The compression can be caused by skeletal abnormalities, swelling of other tissues within the tunnel, or thickening of the retinaculum.
It is often associated with pregnancy, rheumatoid arthritis, diabetes, myxoedema, previous trauma and osteoarthritis, which all reduce the change in pressure/volume relationship.
Age and sex Carpal tunnel syndrome is common in middle-aged females, especially at the menopause.
Local symptoms Pins and needles in the fingers, principally the index and middle fingers, is the common presenting symptom.
The thumb is sometimes involved.
Theoretically, the little finger should never be affected, as it is innervated by the ulnar nerve, but occasionally patients complain that the whole of their hand tingles.
Pain in the forearm may also occur.
For some (so far unexplained) reason, patients often complain of a pain that radiates from the wrist, up along the medial side of the forearm.
There may be an associated loss of hand function.
As the compression increases, the axons in the nerve are killed, and objective signs of nerve damage appear.
Because the sensitivity of the skin supplied by the median nerve is reduced, the patient notices that she drops small articles and cannot carry out delicate movements.
Note that this is not caused by a loss of muscle power, but by the loss of fine discriminatory sensation.
Ultimately, if the nerve damage is severe, there may be a loss of motor function, which presents as weakness and paralysis of the muscles of the thenar eminence and the first two lumbricals (see median nerve palsy in Chapter 3).
Patients are often woken in the middle of the night by their symptoms.
This feature is difficult to explain, but is so characteristic that it is considered to be pathognomonic of the condition.
General symptoms An increase in weight commonly exacerbates the symptoms of carpal tunnel syndrome.
A change in weight may be secondary to another disease such as myxoedema, diabetes or steroid therapy, or to physiological water retention, as in pregnancy.
The patient may have symptoms of arthritis in the wrist and other joints if the condition is secondary to rheumatoid arthritis or osteoarthritis.
Inspection The hand usually looks quite normal, except in advanced cases, where there may be visible wasting of the muscles forming the thenar eminence (Fig.
Palpation Pressure on the flexor retinaculum does not produce the symptoms in the hand, but holding the wrist fully flexed for 1 or 2 minutes may induce symptoms.
Light-touch sensitivity and two-point discrimination may be reduced in the skin innervated by the median nerve (palm, thumb, index and middle finger).
The loss of muscle bulk in the thenar eminence may be easier to feel when these muscles are contracting.
Abduction, adduction and opposition of the thumb may be weak, but the muscles that cause these movements are seldom completely paralysed.
First, you must exclude other causes of paraesthesia in the hand, such as cervical spondylosis, cervical rib, peripheral neuritis and rare neurological disease. This requires a detailed examination of the head, neck and arm.
Second, you must look for evidence of the cause of the carpal tunnel syndrome, such as pregnancy, rheumatoid arthritis, osteoarthritis or myxoedema.
This is a deformity in which all the fingers are permanently flexed (Fig.
Although an ulnar nerve paralysis makes the hand claw-like, because it causes flexion of the ring and little fingers, it does not cause a true claw hand, because only part of the hand is involved.
The causes of claw hand are neurological and musculoskeletal (see Revision panel…
Neurological causes
the causes of claw hand (main en griffe)
Combined ulnar and median nerve palsy Volkmann’s ischaemic contracture Advanced rheumatoid arthritis Brachial plexus lesion (medial cord) Spinal cord lesions:
the deformity is caused by a loss of motor function, there is often an associated sensory loss:
– trauma to the medial roots and cords, especially birth injuries of the lower cord, as in Klumpke’s paralysis; infiltration of the brachial plexus by malignant disease.
– traumatic division of the median and ulnar nerves; peripheral neuritis.
This is a condition in which a finger gets locked in full flexion and will only extend after excessive voluntary effort, or with help from the other hand.
When extension begins, it does so suddenly and with a click…
The condition is caused by a thickening of the flexor tendon or paratenon, or a narrowing of the flexor sheath, preventing movement of the tendon within the flexor sheath.
Symptoms The patient complains that the finger clicks and jumps as it moves, or gets stuck in a flexed position.
A trigger finger is not usually a painful condition, even when force is required to extend it.
Cause The patient can occasionally recall an injury to the palm of the hand, which may have caused the tendon or tendon sheath to thicken, but in most cases there is no indication of the cause.
Inspection The patient will show you how the finger gets stuck and how it snaps out into extension.
Palpation and movement The thickening of the tendon or tendon sheath can be felt at the level of the head of the metacarpal bone.
This is a fixed flexion deformity of the distal interphalangeal joint of a finger, caused by an interruption of the extensor mechanism, either by a rupture of the extensor tendon, or by an avulsion fracture of its insertion.
It is also known as ‘baseball’ finger because the most common cause of the injury is a blow on the tip of the finger by a ball or hard object that forcibly flexes it against the pull of the extensor tendon, which then ruptures or pulls off the bone.
The patient usually remembers the original injury but, if the finger is not painful, may not complain about it until the deformity is established and a nuisance.
Symptoms The inability to extend the tip of a finger is not a great disability, but for a person with an occupation that requires fine finger movements, including full extension of the distal interphalangeal joints, the deformity can be a serious handicap.
When the patient holds out their hand, with the fingers extended, the distal phalanx of the affected finger remains flexed to 15–20° (Fig.
Heberden’s nodes are commonly found on the dorsal surface of the fingers just distal to the distal interphalangeal joint.
They are not mobile, and can be easily recognized as part of the underlying bone (Fig.
The joint movements may be slightly restricted by osteoarthritis, and there may be radial deviation of the distal phalanx.
The index finger is most often affected.
Small adventitious bursae may develop between the skin and the nodes.
Comment Heberden’s nodes do not indicate any specific underlying bone or joint disease, and have no clinical significance.They should not be confused with rheumatoid nodules, which are areas of necrosis
‘Swan neck’ deformity of the fingers
This deformity is hyperextension of the proximal interphalangeal joint, and flexion of the distal interphalangeal joint.
surrounded by fibroblasts and chronic inflammatory cells, and are found in all types of connective tissue.
Patients with rheumatoid nodules invariably have other evidence of rheumatoid arthritis.
All the deformities of rheumatoid arthritis result from the combination of an uneven pull by the tendons and destruction of the joint surfaces.
Boutonnière deformity
(a) opposite of those of the ‘swan neck’ deformity: flexion of the proximal interphalangeal joint, and hyperextension of the distal interphalangeal joint (Fig.
Thickening of the joints
The joints most affected are the metacarpophalangeal and the proximal interphalangeal joints.
Swelling of these joints gives the finger a fusiform, spindle shape.
Ulnar deviation of the fingers
The fingers are pulled towards the ulnar side of the hand, causing a varus deformity at the metacarpophalangeal joints.
Flexion of the wrist
The wrist joint develops a fixed flexion deformity and usually some ulnar deviation (Fig.
In severe rheumatoid arthritis, any tendon may undergo attrition (damage from friction) and rupture.
The most common tendons to rupture are the long extensor tendons of the fingers and thumb.
This is a term that is applied to an effusion in the synovial sheath that surrounds the flexor tendons.
In the UK, it is now invariably secondary to rheumatoid arthritis, but in many other parts of the world it is almost always caused by a tuberculous synovitis.
The most common presenting symptom is swelling on the anterior aspect of the wrist and sometimes in the palm of the hand.
Pain is uncommon.
The patient may notice crepitus during movements of the fingers.
Paraesthesia may occur in the distribution of the median nerve.
Distension of the flexor tendon synovial sheath produces a soft, fluctuant swelling that can be felt on the anterior aspect of the wrist and lower forearm, and in the palm of the hand.
Because the swelling passes beneath the flexor retinaculum, compression of the lump on one side of the retinaculum makes it distend on the other side.
Crepitus may be felt during palpation and when the patient moves their fingers.
– commonly called ‘melon seed bodies’.
There are no local signs of inflammation.
the joints should be examined to exclude rheumatoid arthritis, and the chest should be examined (and X-rayed) to exclude tuberculosis.
Splinter haemorrhages are small extravasations of blood from the vessels of the nail bed caused by minute arterial emboli.
They are long, thin, red– brown streaks, their long axis running towards the end of the finger.Their colour and shape make them look like splinters of wood beneath the nail (see Fig.
The presence of splinter haemorrhages is an important physical sign because they are usually caused by emboli from a bacterial endocarditis or a fulminating septicaemia.
They may also occur in rheumatoid arthritis, mitral stenosis and severe hypertension.
If you look at your finger from the side, you will see that the plane of the nail and the plane of the skin covering the base of the nail bed form an angle of 130–170° (see Chapter 1).
In clubbed nails, there is hypertrophy of the tissue beneath the nail bed, which makes the base of the nail bulge upwards, and distorts nail growth so that the nail becomes curved.
The terminal phalanx may enlarge to make the end of the finger bulbous (Revision panel 4.11).
(Koilonychia) A normal nail is convex transversely and longitudinally, the degree of curvature varying considerably from person to person.
Loss of both these curves produces a hollowed-out spoon-shaped nail (koilonychia) (see Fig.
When a patient complains that their nails have changed from a normal to a spoon shape, it is very likely that they have developed anaemia following chronic loss of blood, usually from menorrhagia or haemorrhoids.