A 52-year-old man comes to the office due to difficulty using his left hand. Over the last year, he has had progressive stiffness at the palm and third and fourth digits, which has led to difficulty doing yard work and typing at his computer. The patient has tried splints and warm compresses without relief. He has no history of trauma to the hand and no other musculoskeletal issues. On examination, the patient has decreased extension at the left third and fourth metacarpophalangeal joints. Findings of the left hand examination are shown below: Which of the following is most closely associated with this patient's condition?

Question

A 52-year-old man comes to the office due to difficulty using his left hand.  Over the last year, he has had progressive stiffness at the palm and third and fourth digits, which has led to difficulty doing yard work and typing at his computer.  The patient has tried splints and warm compresses without relief.  He has no history of trauma to the hand and no other musculoskeletal issues.  On examination, the patient has decreased extension at the left third and fourth metacarpophalangeal joints.  Findings of the left hand examination are shown below:  Which of the following is most closely associated with this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ac_99a5_8f63_7376f9deba07_MD0005_00 This patient's findings are consistent with Dupuytren contracture (DC) at the base of the third and possibly fourth digits. DC is characterized by progressive fibrosis of the palmar fascia. Although the etiology is unknown, risk factors include age >50, male sex, family history, and Northern European ancestry. DC occurs more commonly in patients with a history of smoking and alcohol use. In addition, some studies have shown that up to 40% of patients with DC have diabetes mellitus. DC begins with thickening along the flexor tendons near the distal palmar crease. As the condition progresses, patients may develop discomfort, nodules, and fibrous cords, leading to contractures with decreased extension. The diagnosis is made clinically and does not require imaging. Mild cases can usually be managed with modification of hand tools (eg, padded gloves, cushion tape). Persistent or progressive disease may require needle disruption of cords (aponeurotomy) or intralesional glucocorticoid injections. Surgery is occasionally required for advanced disease or contractures. (Choice A) Acromegaly is characterized by the coarsening of facial features and enlargement of the hands and feet. Patients often notice an increase in ring or glove size and thickening of the skin, but palmar contractures are not typical. Other complications include arthritis, peripheral neuropathy, and carpal tunnel syndrome. Acromegaly (Choice B) Common skeletal manifestations of ankylosing spondylitis include back pain, sacroiliitis, dactylitis (swelling of fingers and toes), and enthesitis (tenderness at tendon insertion sites). DC is not commonly associated with ankylosing spondylitis. (Choice D) Hypertrophic osteoarthropathy is characterized by digital clubbing and bony swelling of the toes and fingers. Causes include pulmonary diseases (eg, cystic fibrosis), malignancy (eg, lung adenocarcinoma), and cyanotic heart disease. Periostitis may cause pain in the digits, but the palmar fascia and tendons are not affected. clubbing (Choice E) Extradermal manifestations of psoriasis include nail pitting, dactylitis, and psoriatic arthritis, but the risk of DC is not significantly increased. Educational objective: Dupuytren contracture is characterized by progressive fibrosis of the palmar fascia. It presents with thickening and nodule formation along the flexor tendons near the distal palmar crease, leading to contractures with decreased extension. Risk factors include age >50, male sex, family history, Northern European ancestry, and diabetes mellitus. References: Hand disorders associated with diabetes: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26280955)

A 52-Year-Old Man Comes to the Office Due to Difficulty