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Dupuytren Disease for Orthopaedic Exams
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Dupuytren Disease for Orthopaedic Exams
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Language: EN.
Segment:0 .
We are started reporting. Good evening, everyone. We have today, some year ago, while they will give us a presentation about dupuytren disease and its complications. Mike was here. Hi, good evening, everyone.
I'm going to talk to you about Du Prince contracture. If you're taking an exam in the UK, this is a fairly common topic, it will appear either in one of your short cases or it does appear as a hand waiver question. This is quite common in this part of the world, although it is not so commonly seen in Asia. So when I came to UK, I was quite new. I did not know what the contracted is other than the book pictures.
I'm just trying to give an outline of Prince contractor, which will suffice hopefully for both your waiver questions as well as if it comes up as a short case. So basically, I'll be talking around these points, history, relevant tenotomy pathology, clinical presentation, treatment options, learning points and a conclusion.
So history just a little bit. The gentleman on the left side of your screen, he's. The gentleman on the right side. He is, said ashley-cooper. Athletes are ashley-cooper describe this disease before duping France. However, DuPont was the first person who published it. And he also published an account of its treatment. So essentially, the person who published it first gets the credit.
His name is associated with this disease. Now But the first description of blueprints goes to flexo-pronator, and this gentleman described this in 1614. He was the first one who actually threw his anatomical studies could prove that Du Prince is a problem with the fascia, not as a shortening of the flexor tendon.
So this formed the basis of the Du Prince disease anatomical background. Now, a basic features in a nutshell, it is essentially a progressive contractor as a part of the proliferative disorder. The associated conditions, which are of which are sometimes seen with blueprints are Garrett's parts medical disease, which is contracted in the Seoul and Peyronie's disease, which is a contract to independence.
It is common in meals, vacations 5 to 6/7 decade of life. There has been an association with the group, which Vikings have traveled. There has also been certain theories about its association with diabetes, with. Started with epilepsy. With HIV, but none of these things have actually been proven.
And even occupation. Kim has been sometimes particularly people working with hand tools. It has been attributed to that. But then there is no causative association to these things. No, coming to the anatomy. Essentially, essentially the most important part is the Bomber fascia, which which has. Five components the Palmer fascia, the Palmer digital fascia, the digital fascia, medial epicondylitis and ulnar nerve upon neurosis, the central fascia here, the central fascia is the zone of maximum activity.
It is a triangular shell layer with its apex prop. Important thing to note is that the fibers are oriented longitudinally, transversely and vertically. The longitudinal fibers fan out as pretending as bands in the centimeters digits. The transverse fiber make up the meditatively ligament, as well as so this is the mattress sutures ligament, as well as the transverse ligament.
Now in my next slide here, I want you to see the vertical fibers, which are known as underwear. Remember these names for the exam, particularly if you're not very sure. Don't put these names if this is a viable question. They may go into a little bit. Of the.
Medical basis is that the palmar aponeurosis has components which go into the digits. They are run longitudinally transversely as well as vertically down, connecting the skin to the bone. The multi-directional arrangement of the coalition favors. Essentially is important in preventing the sharing of the skin of palm while gripping something.
In Dublin's disease, the normal facial burns become diseased cards. Typically, these cards progressively shorten, leading to joint and soft tissue contractures. These short cards cause joint deformity and the long standing flexion deformity needs to contractor of the capsular ligament structures.
No a commonly asked questions, what are the bands, what are the cards, the bands are the normal structures. Cards are the pathological structures which are responsible for the joint contractures. The micro cards are busiest vertical bands, which causes skin pits. Then we come to the pretensioners bands, the pretenders bands are formed the pre-tournament cards and are responsible for carpometacarpal joint contracts.
So if you have a picture or a patient with isolated carpometacarpal joint contract, what you're creating is the free containers card. If there is an additional involvement of the. Proximal of joint or the P&P joint, there is presence of a spinal cord, a spinal cord develops from four structures the pretending to span the spinal band, the lateral digital sheath and the Glisson ligament.
This is an important or a commonly asked question what does spinal cord develop from? People remember these four names the Peter in car, the spiral van. The digital cheat and the Mason ligament. So the other one, the Cleveland ligament is not apart, is not involved in the contract. That is again, sometimes a question. What particular ligament or facial structure is not involved in due process?
And that answer is clean and ligament. Then you have digital cards, which may be central lateral or retro vascular codes. Two additional cards, which you need to know is the abductor digit immediately card, which causes the contractors of the little finger and the card, which which causes the contractor of the thumb. Too much.
How am I going too fast? No, no, I have one comment if you allow me. Yes, please. I am remembering the record and it's called us by a name. Spiral is spiral bend. Band B Britain has penned a letter on digital cheat and the other one is the Greeson Nigam in to good. Yeah, so I'm writing spiral. And the good thing is, of course, depends from it.
Yeah very good. One important thing about the spinal cord. It initially spirals around the neurovascular bundle. If you look closely into the Picture It and once it contracts, it actually straightens and it causes the neurovascular bundle to spiral around it, displacing the vascular bundle to come more proximal, superficial and towards the middle of the digit.
This becomes very important when we are talking of a surgical fistula to me because the. The neurovascular bundle is displaced by the spinal cord. A word about pathophysiology. My fibroblastic is the culprit cell. It differs from fibroblasts by the presence of intracellular actin. It also produces extracellular fiber neck pain, which along with the adjacent cells, produces the.
Contract issue, there is a predominance of three collisions, no, this time. III collagen differs from I collagen in its structure and is the basis of use of CCH or the Clostridium collagen is. Some cytokines, which have commonly been attributed in the activity of nutrients are the TGF beta 1 to epidermal growth factor PDGF.
And connective tissue growth factor don't need to remember all of them, but to name a few, especially TGF beta 1 to epidermal growth factor is important. Clinical presentation is generally in three phases during the early phase. That is skin changes, loss of normal architecture and formation of skin pits.
Nodules and spitting appears in the hand in the intermediate stage. There is the nodules regress and there is formation of the car latest. It develop into contractures. The ring finger is the most commonly involved digit followed in the order of frequency by small, long index finger and the thumb.
So no, if. You are faced with a case in the clinics, it is a sharp case. My advice would be if you have recognized it and if you're sure about it saved. Do not take a long time before spelling out the diagnosis because Du Prince is quite correct to. This is an early difference, which shows thickening of the Palmer skin along with prisoners of nodules, or you may have a case presenting presented to you like this, which has extensive contractures affecting multiple digits where you can actually palpate the cards.
In some cases, there may be a presence of garage parts. I'll come to it in a bit of time. So keep in mind, keep talking to the patient, so you have seen a patient, you think it is a prince, say that you think it is a difference affecting whichever fingers are involved or.
The Houston tabletop test for screening, but make sure that the examiners see you doing it and. Tell them that because the patient is unable to put his hand flat on the table, the Houston tabletop test is positive. Keep talking to your patient, as you would do in your clinic. It is very important because what we need to know is what is this particular person you are seeing?
Is facing due to the presence of doctors, you may have somebody who has very limited activity and may not be affected much by his deformity in the hand, or you may have someone who is very active person and even minimal deformity caused by Du Prince is giving him grief. Some common activities which are usually affected by the are like washing one, washing one's face, doing gloves, putting hand in the pocket, even a handshake.
Greg, to ask about how they are coping up with their activities of daily living and hobbies also try to find out their expectations. Look around if there is a finger on your meter, pick it up. If there is multiple digit involvement, do not waste time measuring each joint. Quickly do an assessment of the join function of the overall hand function and try to ascertain the involved digits and the joints.
If there is no new meter, say that you will use a new meter in the clinic to record the contractors of individual joints for a future reference. Each joint in every finger must be assessed and recorded. After doing the contractor assessment to check the sensation and perform a finger Allen test on each finger.
This is particularly very important if the patient has previously been operated or it is a recurrent disease. Look at the extensive surface of the hand mentioned, what you are looking for is I'm looking for garrus part. Why are you looking for that expert? It is a part of the new Prince diocese. If there is a doctrine that is you expect a strong gene expression.
These patients may present earlier in life they have an aggressive development and there may be a presence of ectopic disease, either in the soul or in the penis. And these are the. People who are particularly at risk of a higher rate of recurrence and surgical complications. Du Prince is a clinical diagnosis.
There is no diagnostic investigation. However, my careful clinical examination, you must exclude a log trigger finger. Ruptured surgical band nodules seen in hypercard, this occupational thickening and epithelial sarcoma. The once you have reached the stage, you have done your examination.
You have reached your diagnosis and then the next. How are you going to manage it? So one of the important aspect of deterrence management is that it. Is it a frequent expense has been defined as an increase in the joint contract to more than 20 degrees as compared to that contract six weeks?
So essentially, if a different case is followed up long enough, they all will recur. It's just a matter of how long they have been followed up. So there is a lot of management options, observation, limited intervention and operative treatment. No but not every treatment is suitable for every patient. Someone who has a very early disease, he may he will not benefit by any particular intervention as we don't know how the disease is going to progress.
So it is best to advise him a supervised observation. And then at the other end of the spectrum, there is somebody who has a recurrent disease, which you feel that is not easy to correct or is not going to be fully corrected, and his overall function may be improved by the amputation of that digit, although it is pretty radical. I avoid mentioning amputation in the exam. No, in the end I will again.
Put a link to this paper. This is an excellent paper by Professor David Warwick. He describes the cards as logs or twigs. Logs are pin cards with good overlying skin and logs are take structures with advent leather like the skin. And, according to this paper, is their treatment options are really different for each one of them.
Now, the choice of treatment essentially depends upon we all know the severity of disease, the degree of disability it causes, the surgical fitness of the patient. What is the patient's expectations? Surgeons own experience and aptitude and then taking into account the possibility of recurrence and complications and hydroapatite for the same.
Is there a treatment, which is superior from 1 to the other? The good qualities are cities on different disease is quite rare. There are so many reasons about it. One of the most important is it is a heterogeneous disorder. It's not. So it's like comparing apples to oranges. Plus, the definition of recurrence and the definition of perfection has still not been finalized.
Now coming on to each treatment modality. An elderly gentleman who is not fit for a major surgical procedure with minimal disease and very well localized card may be a candidate for a poor cutaneous facial. To me in this essentially needle type is used to just physically divide the card. You neither remove the cell nor the matrix, but just provide an extension.
Works quite well for this scores. Another common thing is Clostridium is political. It has been approved by nice as a treatment of one or two guards, particularly more disease. It is good for treatment of MCP contracture, but does not very well address the VIP contract.
It dissolves the matrix, but the cells persist. They had worn pages. It is like an OPD procedure can be repeated on the same hand up to three times. One of the major. Disastrous complication is a flexor-pronator rupture. It is reported in one in 500. The reason being the flexor-pronator share Colgan three, and if the Egyptian refuses, it may dissolve the tendon.
So this is how the injection is placed now on the day of injection, after the following day, the patient is seen in the clinic when there may be some bruising and swelling of the hand. A local anesthetic is given and then the card is gently manipulated. There has been recent.
A discussion about the effectiveness of CCH versus PMF, if you're interested, you can go through these papers. Essentially, some people mentioned that it is better, but then again, there is growing evidence that CCH is only as effective as needed for shortening. No, this is something we must all know about. Limited Fisher penny. This is the most common surgical intervention for primary disease.
You might be asked, have you seen any have you done any? And the commonly employed skin incisions are either the utility incision or you do a longitudinal incision and then later close it by doing multiple z plastic. The moment you mentioned that plastic you can, you may be asked to draw that plastic on a piece of paper.
Practice it a few times, appear confident and you'll be winning a certain point there. So one of the important thing is with any due surgery, the neurovascular bundle is at risk. If you look at this picture, the neurovascular bundle is quite close to the deceased card and the spirals superficial to it, whereas actually it should be deeper to it.
So this particular change in the direction of the neurovascular tendon makes it quite vulnerable to injury during the procedure. No as I mentioned, if there is a diffused disease with leathery skin or thickened skin, or there is a possibility that the skin may not be sufficient to cover the whole area, then excision of the skin is undertaken along with a full thickness graft usually taken from the.
Upper arm or the medial aspect of the arm where there is skin available without. Many hair follicles. And then this also has the advantage that the fresh skin acts like a fire break. Uh, it is said that the recurrence rate after this procedure is considerably lower than all of the procedures as it removes all the cells, including those residing close to the skin, McIndoe and bare promoted radical Fisher.
To me, although this is no longer practice, it is more studied because and this has got a higher incidence of wound complications and kind of stiffness. Special mention to PIP joint contractors, as we all know, MCP joint, if they're flexed for a long time is still the collateral ligaments do not get contracted, whereas for the pipe joint, if they are kept flags, the collateral ligaments contract the will to play contracts and release of the spinal cord may not result in.
Good correction. Several authors have noted that PIP joint release is not advisable, as this either results in an early recurrence or stiffness that is not very well tolerated by the patient. Complications that you need to remember about is. Intra operative complications are nerve injury in primary cases, 1% to 2% in revision cases, up to 6% to 8% Arterial injury can cause cold intolerance.
A button hole in the skin flap during surgery, although no disaster early post-op. Complications, formation of hematoma, swelling, infection in one Mason, the late complications are recurrent. And chronic regional pain syndrome, definitely in any hands of the patient. You do mention as a possible common. Sorry so what have we learned so far?
Get your money fast if you have made the diagnosis. Spell it out, don't wait. Precise description of the deformity. Where where is the contractor? How much is the contractor? Do not miss the neurovascular status of the finger. As far as possible, Tread to a certain patient's disability and expectation before offering advice regarding treatment.
Discuss the treatment option. Whatever you are trying, what your treatment option is in that particular patient, have some justification. Do not suggest something which you are not very sure. This was the paper which I mentioned that. If you read this paper, it's about six pages. This contains a lot of information about doctrine. It is a pretty recent paper 2017.
We'll give you a good overview. Plus the paper comes from Professor Warwick, so it has got a good. So close. That's the end of my talk. Excellent presentation. Smear if anyone has any question we can, we can ask each share in the chat books.
If no one has any questions, I'd like to ask the doctor, no question the what's your view and what's the take for the exam in terms of collagen is injections are the best thing would be it is it?
Till date, it is a recommendation by nice to be used by a specialist handguns. Potent so there are certain limitations put by nice. So we must because we are answering in the exam, we must stick to those guidelines. So by especially this time consultant in an outpatient setting for a moderate disease. Isolated, caught.
So these are the indications there has been some recent discussions. Should remember societies, I have been to 1 recently where they are talking that possibly the company itself is in a process of drawing this out of the market, but as of now, it is not withdrawn. So if the exams are in February. And if anything changes in January because there was some discussion that things might change in January.
So what I would say is as an answer, yes, college is an option in specialist hands. Could I would agree with that, that to say it's an option, but I wouldn't use it as my first option in the example, because. Nice are very specific on when to use it, but also the reason why they're very specific is it's expense. It does have a higher expense and has not been shown to improve or prevent recurrence.
Um, according to some of the papers, it's true there is some papers which are different. Please disagree with me mentors if there is further information. OK Yes a very common question in the paper. They're asking how you can consent the patient for surgery. What you will see the patient.
Right so whenever you are consenting a patient for one, you tell the patient very clearly the surgery is not curative, the surgery is to correct the deformity. OK we don't know the rate of progress. Shame or recurrence of the risk. So in all the benefit of this surgery would be we will have a correction of the deformity which you have, which may improve the function of your hand.
That is the intended benefit you will when you're talking to the patient, you will always tell them about the dangers. Infection wound adhesions, injury to nose vessels and tendons. These are the things you must definitely mention, then risk of recurrence of the disease. Revision surgery chronic regional pain syndrome. Prolonged the stiffness of the hand.
But these are the things which you would include in your concept. Postoperatively right. The post-operative plan, sorry, I think I missed it. The post-operative peel-back is usually the patient is put in a plaster immediately after the release within next 72 hours to four days.
He sees a hand therapist who takes down the plaster, provides them with a thermoplastic splint that they wear 4, 3, 2 four weeks continuously all the time. Then they start mobilizing their hand and they wear the splint only at nighttime for four months. That is what we practice here. OK any more, mccutcheon?
Anything else? I think she covered the whole subject. Sean has muted himself. Sorry my apologies. Yes I'm just going to go to one of the controversial areas, see, because. Because that can come up in the exam drama Academy is limited. And one has a bit an advantage to the other.
Why not do react to me because you're decreasing the risk of recurrence? One of the things is limited facial. To me is a much more smaller procedure than doing a economy. Second thing is if. You do a double feature to me, and there is a graft complication you face with a much larger wound as to a wound complication in a limited patient. Excellent.
Thank you. So that brings up, that's well covered, I think pretty much everything. Really good presentation. Thank you. Mustafa, I would suggest now is if there's nothing, I would suggest that we stop and thank you to the mentors for attending.
Segment:0 .
We are started reporting. Good evening, everyone. We have today, some year ago, while they will give us a presentation about dupuytren disease and its complications. Mike was here. Hi, good evening, everyone.
I'm going to talk to you about Du Prince contracture. If you're taking an exam in the UK, this is a fairly common topic, it will appear either in one of your short cases or it does appear as a hand waiver question. This is quite common in this part of the world, although it is not so commonly seen in Asia. So when I came to UK, I was quite new. I did not know what the contracted is other than the book pictures.
I'm just trying to give an outline of Prince contractor, which will suffice hopefully for both your waiver questions as well as if it comes up as a short case. So basically, I'll be talking around these points, history, relevant tenotomy pathology, clinical presentation, treatment options, learning points and a conclusion.
So history just a little bit. The gentleman on the left side of your screen, he's. The gentleman on the right side. He is, said ashley-cooper. Athletes are ashley-cooper describe this disease before duping France. However, DuPont was the first person who published it. And he also published an account of its treatment. So essentially, the person who published it first gets the credit.
His name is associated with this disease. Now But the first description of blueprints goes to flexo-pronator, and this gentleman described this in 1614. He was the first one who actually threw his anatomical studies could prove that Du Prince is a problem with the fascia, not as a shortening of the flexor tendon.
So this formed the basis of the Du Prince disease anatomical background. Now, a basic features in a nutshell, it is essentially a progressive contractor as a part of the proliferative disorder. The associated conditions, which are of which are sometimes seen with blueprints are Garrett's parts medical disease, which is contracted in the Seoul and Peyronie's disease, which is a contract to independence.
It is common in meals, vacations 5 to 6/7 decade of life. There has been an association with the group, which Vikings have traveled. There has also been certain theories about its association with diabetes, with. Started with epilepsy. With HIV, but none of these things have actually been proven.
And even occupation. Kim has been sometimes particularly people working with hand tools. It has been attributed to that. But then there is no causative association to these things. No, coming to the anatomy. Essentially, essentially the most important part is the Bomber fascia, which which has. Five components the Palmer fascia, the Palmer digital fascia, the digital fascia, medial epicondylitis and ulnar nerve upon neurosis, the central fascia here, the central fascia is the zone of maximum activity.
It is a triangular shell layer with its apex prop. Important thing to note is that the fibers are oriented longitudinally, transversely and vertically. The longitudinal fibers fan out as pretending as bands in the centimeters digits. The transverse fiber make up the meditatively ligament, as well as so this is the mattress sutures ligament, as well as the transverse ligament.
Now in my next slide here, I want you to see the vertical fibers, which are known as underwear. Remember these names for the exam, particularly if you're not very sure. Don't put these names if this is a viable question. They may go into a little bit. Of the.
Medical basis is that the palmar aponeurosis has components which go into the digits. They are run longitudinally transversely as well as vertically down, connecting the skin to the bone. The multi-directional arrangement of the coalition favors. Essentially is important in preventing the sharing of the skin of palm while gripping something.
In Dublin's disease, the normal facial burns become diseased cards. Typically, these cards progressively shorten, leading to joint and soft tissue contractures. These short cards cause joint deformity and the long standing flexion deformity needs to contractor of the capsular ligament structures.
No a commonly asked questions, what are the bands, what are the cards, the bands are the normal structures. Cards are the pathological structures which are responsible for the joint contractures. The micro cards are busiest vertical bands, which causes skin pits. Then we come to the pretensioners bands, the pretenders bands are formed the pre-tournament cards and are responsible for carpometacarpal joint contracts.
So if you have a picture or a patient with isolated carpometacarpal joint contract, what you're creating is the free containers card. If there is an additional involvement of the. Proximal of joint or the P&P joint, there is presence of a spinal cord, a spinal cord develops from four structures the pretending to span the spinal band, the lateral digital sheath and the Glisson ligament.
This is an important or a commonly asked question what does spinal cord develop from? People remember these four names the Peter in car, the spiral van. The digital cheat and the Mason ligament. So the other one, the Cleveland ligament is not apart, is not involved in the contract. That is again, sometimes a question. What particular ligament or facial structure is not involved in due process?
And that answer is clean and ligament. Then you have digital cards, which may be central lateral or retro vascular codes. Two additional cards, which you need to know is the abductor digit immediately card, which causes the contractors of the little finger and the card, which which causes the contractor of the thumb. Too much.
How am I going too fast? No, no, I have one comment if you allow me. Yes, please. I am remembering the record and it's called us by a name. Spiral is spiral bend. Band B Britain has penned a letter on digital cheat and the other one is the Greeson Nigam in to good. Yeah, so I'm writing spiral. And the good thing is, of course, depends from it.
Yeah very good. One important thing about the spinal cord. It initially spirals around the neurovascular bundle. If you look closely into the Picture It and once it contracts, it actually straightens and it causes the neurovascular bundle to spiral around it, displacing the vascular bundle to come more proximal, superficial and towards the middle of the digit.
This becomes very important when we are talking of a surgical fistula to me because the. The neurovascular bundle is displaced by the spinal cord. A word about pathophysiology. My fibroblastic is the culprit cell. It differs from fibroblasts by the presence of intracellular actin. It also produces extracellular fiber neck pain, which along with the adjacent cells, produces the.
Contract issue, there is a predominance of three collisions, no, this time. III collagen differs from I collagen in its structure and is the basis of use of CCH or the Clostridium collagen is. Some cytokines, which have commonly been attributed in the activity of nutrients are the TGF beta 1 to epidermal growth factor PDGF.
And connective tissue growth factor don't need to remember all of them, but to name a few, especially TGF beta 1 to epidermal growth factor is important. Clinical presentation is generally in three phases during the early phase. That is skin changes, loss of normal architecture and formation of skin pits.
Nodules and spitting appears in the hand in the intermediate stage. There is the nodules regress and there is formation of the car latest. It develop into contractures. The ring finger is the most commonly involved digit followed in the order of frequency by small, long index finger and the thumb.
So no, if. You are faced with a case in the clinics, it is a sharp case. My advice would be if you have recognized it and if you're sure about it saved. Do not take a long time before spelling out the diagnosis because Du Prince is quite correct to. This is an early difference, which shows thickening of the Palmer skin along with prisoners of nodules, or you may have a case presenting presented to you like this, which has extensive contractures affecting multiple digits where you can actually palpate the cards.
In some cases, there may be a presence of garage parts. I'll come to it in a bit of time. So keep in mind, keep talking to the patient, so you have seen a patient, you think it is a prince, say that you think it is a difference affecting whichever fingers are involved or.
The Houston tabletop test for screening, but make sure that the examiners see you doing it and. Tell them that because the patient is unable to put his hand flat on the table, the Houston tabletop test is positive. Keep talking to your patient, as you would do in your clinic. It is very important because what we need to know is what is this particular person you are seeing?
Is facing due to the presence of doctors, you may have somebody who has very limited activity and may not be affected much by his deformity in the hand, or you may have someone who is very active person and even minimal deformity caused by Du Prince is giving him grief. Some common activities which are usually affected by the are like washing one, washing one's face, doing gloves, putting hand in the pocket, even a handshake.
Greg, to ask about how they are coping up with their activities of daily living and hobbies also try to find out their expectations. Look around if there is a finger on your meter, pick it up. If there is multiple digit involvement, do not waste time measuring each joint. Quickly do an assessment of the join function of the overall hand function and try to ascertain the involved digits and the joints.
If there is no new meter, say that you will use a new meter in the clinic to record the contractors of individual joints for a future reference. Each joint in every finger must be assessed and recorded. After doing the contractor assessment to check the sensation and perform a finger Allen test on each finger.
This is particularly very important if the patient has previously been operated or it is a recurrent disease. Look at the extensive surface of the hand mentioned, what you are looking for is I'm looking for garrus part. Why are you looking for that expert? It is a part of the new Prince diocese. If there is a doctrine that is you expect a strong gene expression.
These patients may present earlier in life they have an aggressive development and there may be a presence of ectopic disease, either in the soul or in the penis. And these are the. People who are particularly at risk of a higher rate of recurrence and surgical complications. Du Prince is a clinical diagnosis.
There is no diagnostic investigation. However, my careful clinical examination, you must exclude a log trigger finger. Ruptured surgical band nodules seen in hypercard, this occupational thickening and epithelial sarcoma. The once you have reached the stage, you have done your examination.
You have reached your diagnosis and then the next. How are you going to manage it? So one of the important aspect of deterrence management is that it. Is it a frequent expense has been defined as an increase in the joint contract to more than 20 degrees as compared to that contract six weeks?
So essentially, if a different case is followed up long enough, they all will recur. It's just a matter of how long they have been followed up. So there is a lot of management options, observation, limited intervention and operative treatment. No but not every treatment is suitable for every patient. Someone who has a very early disease, he may he will not benefit by any particular intervention as we don't know how the disease is going to progress.
So it is best to advise him a supervised observation. And then at the other end of the spectrum, there is somebody who has a recurrent disease, which you feel that is not easy to correct or is not going to be fully corrected, and his overall function may be improved by the amputation of that digit, although it is pretty radical. I avoid mentioning amputation in the exam. No, in the end I will again.
Put a link to this paper. This is an excellent paper by Professor David Warwick. He describes the cards as logs or twigs. Logs are pin cards with good overlying skin and logs are take structures with advent leather like the skin. And, according to this paper, is their treatment options are really different for each one of them.
Now, the choice of treatment essentially depends upon we all know the severity of disease, the degree of disability it causes, the surgical fitness of the patient. What is the patient's expectations? Surgeons own experience and aptitude and then taking into account the possibility of recurrence and complications and hydroapatite for the same.
Is there a treatment, which is superior from 1 to the other? The good qualities are cities on different disease is quite rare. There are so many reasons about it. One of the most important is it is a heterogeneous disorder. It's not. So it's like comparing apples to oranges. Plus, the definition of recurrence and the definition of perfection has still not been finalized.
Now coming on to each treatment modality. An elderly gentleman who is not fit for a major surgical procedure with minimal disease and very well localized card may be a candidate for a poor cutaneous facial. To me in this essentially needle type is used to just physically divide the card. You neither remove the cell nor the matrix, but just provide an extension.
Works quite well for this scores. Another common thing is Clostridium is political. It has been approved by nice as a treatment of one or two guards, particularly more disease. It is good for treatment of MCP contracture, but does not very well address the VIP contract.
It dissolves the matrix, but the cells persist. They had worn pages. It is like an OPD procedure can be repeated on the same hand up to three times. One of the major. Disastrous complication is a flexor-pronator rupture. It is reported in one in 500. The reason being the flexor-pronator share Colgan three, and if the Egyptian refuses, it may dissolve the tendon.
So this is how the injection is placed now on the day of injection, after the following day, the patient is seen in the clinic when there may be some bruising and swelling of the hand. A local anesthetic is given and then the card is gently manipulated. There has been recent.
A discussion about the effectiveness of CCH versus PMF, if you're interested, you can go through these papers. Essentially, some people mentioned that it is better, but then again, there is growing evidence that CCH is only as effective as needed for shortening. No, this is something we must all know about. Limited Fisher penny. This is the most common surgical intervention for primary disease.
You might be asked, have you seen any have you done any? And the commonly employed skin incisions are either the utility incision or you do a longitudinal incision and then later close it by doing multiple z plastic. The moment you mentioned that plastic you can, you may be asked to draw that plastic on a piece of paper.
Practice it a few times, appear confident and you'll be winning a certain point there. So one of the important thing is with any due surgery, the neurovascular bundle is at risk. If you look at this picture, the neurovascular bundle is quite close to the deceased card and the spirals superficial to it, whereas actually it should be deeper to it.
So this particular change in the direction of the neurovascular tendon makes it quite vulnerable to injury during the procedure. No as I mentioned, if there is a diffused disease with leathery skin or thickened skin, or there is a possibility that the skin may not be sufficient to cover the whole area, then excision of the skin is undertaken along with a full thickness graft usually taken from the.
Upper arm or the medial aspect of the arm where there is skin available without. Many hair follicles. And then this also has the advantage that the fresh skin acts like a fire break. Uh, it is said that the recurrence rate after this procedure is considerably lower than all of the procedures as it removes all the cells, including those residing close to the skin, McIndoe and bare promoted radical Fisher.
To me, although this is no longer practice, it is more studied because and this has got a higher incidence of wound complications and kind of stiffness. Special mention to PIP joint contractors, as we all know, MCP joint, if they're flexed for a long time is still the collateral ligaments do not get contracted, whereas for the pipe joint, if they are kept flags, the collateral ligaments contract the will to play contracts and release of the spinal cord may not result in.
Good correction. Several authors have noted that PIP joint release is not advisable, as this either results in an early recurrence or stiffness that is not very well tolerated by the patient. Complications that you need to remember about is. Intra operative complications are nerve injury in primary cases, 1% to 2% in revision cases, up to 6% to 8% Arterial injury can cause cold intolerance.
A button hole in the skin flap during surgery, although no disaster early post-op. Complications, formation of hematoma, swelling, infection in one Mason, the late complications are recurrent. And chronic regional pain syndrome, definitely in any hands of the patient. You do mention as a possible common. Sorry so what have we learned so far?
Get your money fast if you have made the diagnosis. Spell it out, don't wait. Precise description of the deformity. Where where is the contractor? How much is the contractor? Do not miss the neurovascular status of the finger. As far as possible, Tread to a certain patient's disability and expectation before offering advice regarding treatment.
Discuss the treatment option. Whatever you are trying, what your treatment option is in that particular patient, have some justification. Do not suggest something which you are not very sure. This was the paper which I mentioned that. If you read this paper, it's about six pages. This contains a lot of information about doctrine. It is a pretty recent paper 2017.
We'll give you a good overview. Plus the paper comes from Professor Warwick, so it has got a good. So close. That's the end of my talk. Excellent presentation. Smear if anyone has any question we can, we can ask each share in the chat books.
If no one has any questions, I'd like to ask the doctor, no question the what's your view and what's the take for the exam in terms of collagen is injections are the best thing would be it is it?
Till date, it is a recommendation by nice to be used by a specialist handguns. Potent so there are certain limitations put by nice. So we must because we are answering in the exam, we must stick to those guidelines. So by especially this time consultant in an outpatient setting for a moderate disease. Isolated, caught.
So these are the indications there has been some recent discussions. Should remember societies, I have been to 1 recently where they are talking that possibly the company itself is in a process of drawing this out of the market, but as of now, it is not withdrawn. So if the exams are in February. And if anything changes in January because there was some discussion that things might change in January.
So what I would say is as an answer, yes, college is an option in specialist hands. Could I would agree with that, that to say it's an option, but I wouldn't use it as my first option in the example, because. Nice are very specific on when to use it, but also the reason why they're very specific is it's expense. It does have a higher expense and has not been shown to improve or prevent recurrence.
Um, according to some of the papers, it's true there is some papers which are different. Please disagree with me mentors if there is further information. OK Yes a very common question in the paper. They're asking how you can consent the patient for surgery. What you will see the patient.
Right so whenever you are consenting a patient for one, you tell the patient very clearly the surgery is not curative, the surgery is to correct the deformity. OK we don't know the rate of progress. Shame or recurrence of the risk. So in all the benefit of this surgery would be we will have a correction of the deformity which you have, which may improve the function of your hand.
That is the intended benefit you will when you're talking to the patient, you will always tell them about the dangers. Infection wound adhesions, injury to nose vessels and tendons. These are the things you must definitely mention, then risk of recurrence of the disease. Revision surgery chronic regional pain syndrome. Prolonged the stiffness of the hand.
But these are the things which you would include in your concept. Postoperatively right. The post-operative plan, sorry, I think I missed it. The post-operative peel-back is usually the patient is put in a plaster immediately after the release within next 72 hours to four days.
He sees a hand therapist who takes down the plaster, provides them with a thermoplastic splint that they wear 4, 3, 2 four weeks continuously all the time. Then they start mobilizing their hand and they wear the splint only at nighttime for four months. That is what we practice here. OK any more, mccutcheon?
Anything else? I think she covered the whole subject. Sean has muted himself. Sorry my apologies. Yes I'm just going to go to one of the controversial areas, see, because. Because that can come up in the exam drama Academy is limited. And one has a bit an advantage to the other.
Why not do react to me because you're decreasing the risk of recurrence? One of the things is limited facial. To me is a much more smaller procedure than doing a economy. Second thing is if. You do a double feature to me, and there is a graft complication you face with a much larger wound as to a wound complication in a limited patient. Excellent.
Thank you. So that brings up, that's well covered, I think pretty much everything. Really good presentation. Thank you. Mustafa, I would suggest now is if there's nothing, I would suggest that we stop and thank you to the mentors for attending.
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