Dupuytren's Contracture by gjjur4356

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									Dupuytren’s Contracture

  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

 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
 Patients usually have        aponeurosis; this band
  difficulty with tasks such   may progress to skin
  as face washing, hair        tethering, puckering, or
  combing, and putting         pitting.
  their hands in their        Grade 2 presents as a
  pockets.                     peritendinous band, and
 Note the site of the         extension of the affected
  nodule and the presence      finger is limited.
  of contractures; bands;     Grade 3 presents as
  and skin pitting,            flexion contracture
  tenderness, and dimpling.


 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

     Associated Findings
 History of trauma,              Other disorders commonly
  childhood abuse, anxiety,        associated with FM include:
  depression, or sleep
                                  Irritable bladder
  disorder (alpha frequency
  rhythm, termed alpha-delta      Dysmenorrhea
  sleep anomaly )                 Premenstrual syndrome
 Patients with high tender       Restless leg syndrome
  point counts are more likely    Temporomandibular joint
  to report adverse childhood      pain
  experiences like loss of a      Noncardiac chest pain
  parent or abuse
                                  Raynaud's phenomenon
 Irritable bowel syndrome         and Sicca syndrome
  (IBS)                            (Sjogren‟s)

 Myofascial pain syndrome,
 Chronic fatigue syndrome, and
 Hypothyroidism.

   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
  Chronic fatigue syndrome
 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.

 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
 (The differential diagnosis also might include
  metabolic and inflammatory myopathies
  (especially in patients taking statins),
  polymyalgia rheumatica, and other rheumatic
  diseases. )

 optimal intervention is an approach that
  also includes nonpharmacologic treatments,
  specifically exercise and cognitive behavior
 education, cognitive behavior strategies,
  physical training, and medications for
  treatment of fibromyalgia


Multi symptom

 Multi symptom condition
 characterized by chronic widespread

Muscular pain         Numbness
Fatigue               Impaired memory
Sleep abnormalities   Leg cramps
Joint pain            Impaired
Headaches              concentration
Restless legs         Nervousness
                       Major depression

Patient-Reported Symptoms at
Diagnosis of Fibromyalgia

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

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

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


     ?TREATMENT Eval Criteria
          SYMPTOM                 CRITICAL FOR EVAL%
             Pain                        100
           Fatigue                       94
       Patient global                    94
Multidimensional function                86
        Tenderness                       74
            Sleep                         66
 Health-related quality of life           65
        Dyscognition                      61
           Stiffness                     60

   Current Knowledge About
‘Off label’               FDA „approved‟
SNRIs                     Pregabalin(Lyrica)
Anticonvulsants           Duloxetine
Tricyclic                  Hydrochloride (Cymbalta)
 antidepressants (TCAs)    Milnacipran
Muscle relaxants           Hydrochloride(Savella)
Nonsteroidal anti-
 inflammatory drugs
 (NSAIDs) and
 (COX2) inhibitors
Pregabalin                Duloxetine                 Milnacipran
(Lyrica)                  Hydrochloride              Hydrochloride
                          (Cymbalta)                 (Savella)
Alpha2 receptor           SNRI                       SNRI
150-225 mg bid            60 mg/d                    50 mg bid (start 12.5
75 mg bid                 Start 30 mg/d for 1        mg/d, increase on day 2
May increase to 150 mg    wk, increase to 60         to 12.5 mg bid,
bid within 1 wk           mg/d                       on day 4 to 25 mg bid,
Maximum dose 225 mg                                  after day 7 to 50 mg bid)
bid                                                  Maximum dose 200 mg/d

Angioedema,               Suicidality, orthostatic   Suicidality, orthostatic
hypersensitivity          hypotension, serotonin     hypotension, serotonin
reactions, peripheral     syndrome                   syndrome

Dizziness, somnolence,    Nausea, dry mouth,         Nausea, headache,
dry mouth, edema,         constipation,              constipation,
blurred vision, weight    somnolence,                dizziness, insomnia, hot
gain, difficulty with     hyperhidrosis,             flush, hyperhidrosis,
concentration/attention   decreased appetite         vomiting, palpitations,
                                                     heart rate increase, dry
                                                     mouth, hypertension


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