A 55-year-old man comes to the office due to a hard lump on the palm of his right hand that has been present for several months. It is painless and does not affect hand function. Medical history is significant for type 2 diabetes mellitus and hypertension. The patient works as a gardener. Vital signs are normal. On examination, a hard, fibrous, nodular band is present at the base of the ring finger. He has full movement of his fingers. What is the most likely cause of this patient's current condition?

Question

A 55-year-old man comes to the office due to a hard lump on the palm of his right hand that has been present for several months.  It is painless and does not affect hand function.  Medical history is significant for type 2 diabetes mellitus and hypertension.  The patient works as a gardener.  Vital signs are normal.  On examination, a hard, fibrous, nodular band is present at the base of the ring finger.  He has full movement of his fingers.  What is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d86c_841a_bc81_f14b5b63c4c0_MD0003_00 This patient has Dupuytren contracture (DC) at the base of the ring finger. DC is characterized by progressive fibrosis of the palmar fascia due to fibroblast proliferation and disordered collagen deposition. Although the etiology is unknown, risk factors include age >50, male sex, family history, and Northern European ancestry. Manual work (eg, gardening) may also be a risk factor, and DC occurs more commonly in patients with a history of tobacco and alcohol use and diabetes mellitus. Initial fascial fibrosis results in painless puckering of the skin just proximal to the metacarpophalangeal joint. As fibrosis continues, pathognomonic fascial nodules form along the flexor tendons and eventually progress to palpable fibrotic cords. Although patients may initially have full movement in their fingers (as seen in this patient), formation of these cords eventually results in contractures that lead to decreased extension at the metacarpophalangeal and proximal interphalangeal joints. The ring and little fingers are most commonly involved, with the middle finger involved to a lesser extent. puckering of the skin cords 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. (Choices A and D) Calcific peritendinitis is an inflammatory condition caused by calcium hydroxyapatite crystal deposition in the tendons. Flexor tenosynovitis is inflammation of the tendons and their synovial sheaths, typically caused by bacterial infections. Because of the inflammatory nature of both conditions, they present with pain, erythema, and swelling, features absent in DC. (Choice B) Diabetic cheiroarthropathy ("diabetic stiff hand syndrome") occurs in patients with long-standing diabetes mellitus. Decreased collagen degradation leads to thickened scleroderma-like skin, sclerosis of the tendon sheaths, and stiffness in the joints. However, fibrotic nodules and cords, which are pathognomonic for DC, are not present. (Choice E) Diabetes mellitus is a risk factor for median nerve mononeuropathy at the wrist, which results in numbness in the palmar thumb and the index, middle, and ring (radial half) fingers, as well as weakness in the thenar muscles (eg, thumb abduction and opposition), akin to carpal tunnel syndrome. median nerve Educational objective: Dupuytren contracture results from progressive palmar fascia fibrosis, leading to puckering of the skin and fibrotic nodule and cord formation along the flexor tendons. Patients develop contractures that limit extension at the metacarpophalangeal and proximal interphalangeal joints. The diagnosis is made clinically; no imaging is needed. References: Dupuytren's disease: where do we stand? (http://www.ncbi.nlm.nih.gov/pubmed/30931150)

A 55-Year-Old Man Comes to the Office Due to a Hard