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Spot Diagnosis - Foot

Discussion in 'Spot Diagnosis' started by neo_star, Jan 9, 2013.

  1. neo_star

    neo_star Moderator

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  2. kangourou

    kangourou Famous Member

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    Picture A is dupuytren's contracture, so picture B is plantar fascia fibromatosis (Ledderhose disease)
     

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  3. Emergency medicine Mike

    Emergency medicine Mike Bronze Member

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    Ledderhose disease.
     

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  4. dupuytren

    dupuytren Bronze Member

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    Dupuytren's contracture on the left, Ledderhose disease on the right. Both are superficial fibromatosis.
     

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  5. neo_star

    neo_star Moderator

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    Ans: Condition A is Palmar fibromatosis / Dupuytren's contracture ( and we r lucky to hav him in our midst (-8 )
    Condition B is Plantar fibromatosis / Ledderhose's disease


    I will expand on the topic on Dr. Dupuytren's behalf, with his blessings P:

    Plantar fascial fibromatosis, also known as Ledderhose's disease, Morbus Ledderhose, and plantar fibromatosis, is a relatively uncommon non-malignant thickening of the feet's deep connective tissue, or fascia. In the beginning, where nodules or cords start growing along tendons of the foot, the disease is minor, can be painful. Eventually, however, the cords thicken, the toes stiffen and bend, and walking becomes painful. The disease is named after Dr. Georg Ledderhose, a German surgeon who described the condition for the first time in 1894. A similar disease is Dupuytren's disease, which affects the hand and causes bent hand or fingers.

    Symptoms


    As in most forms of fibromatosis, it is usually benign and its onset varies with each patient.
    Plantar fibromatosis is most frequently present on the medial border of the sole, near the highest point of the arch.
    The lump is usually painless and the only pain experienced is when the nodule rubs on the shoe or floor.
    The overlying skin is freely movable, and contracture of the toes does not occur in the initial stages.

    Occasionally, the nodules may lie dormant for months to years only to begin rapid and unexpected growth.It need only be surgically removed if discomfort hinders walking.
    Only 25% of patients show symptoms on both feet (bilateral involvement).

    Imaging findings

    The typical appearance of plantar fibromatosis on Magnetic resonance imaging (MRI) is a poorly defined, infiltrative mass in the aponeurosis next to the plantar muscles.

    The disease may also infiltrate the dermis or very rarely the flexor tendon sheath.

    Risk Factors

    The histological and ultrastructural features of Ledderhose and Dupuytren's disease are the same, which supports the hypothesis that they have a common etiology and pathogenesis. As with Dupuytren's disease, the root cause(s) of Ledderhose's disease are not yet understood. It has been noted that it is an inherited disease and of variable occurrence within families.

    There are certain identified risk factors. The disease is more commonly associated with -

    A family history of the disease
    Higher incidence in males
    Palmar fibromatosis 10-65% of the time
    Peyronie's disease
    Epilepsy patients
    Patients of diabetes mellitus

    There is also a suspected, although unproven, link between incidence and alcoholism, smoking, liver diseases, thyroid problems, and stressful work involving the feet.



    Treatment

    Although the origin of the disease is unknown, there is speculation that it is an aggressive healing response to small tears in the plantar fascia, almost as if the fascia over-repairs itself following an injury.

    In the early stages, when the nodule is single and/or smaller, it is recommended to avoid direct pressure to the nodule(s). Soft inner soles on footwear and padding may be helpful.

    MRI and sonogram (diagnostic ultrasound) are effective in showing the extent of the lesion, but cannot reveal the tissue composition. Even then, recognition of the imaging characteristics of plantar fibromatoses can help in the clinical diagnosis.

    Surgery of Ledderhose's disease is difficult because tendons, nerves, and muscles are located very closely to each other. Additionally, feet have to carry heavy load, and surgery might have unpleasant side effects. If surgery is performed, the biopsy is predominantly cellular and frequently misdiagnosed as fibrosarcoma. Since the diseased area (lesion) is not encapsulated, clinical margins are difficult to define. As such, portions of the diseased tissue may be left in the foot after surgery. Inadequate excision is the leading cause of recurrence.

    Post-surgical radiation treatment may decrease recurrence. There has also been variable success in preventing recurrence by administering gadolinium. Skin grafts have been shown to control recurrence of the disease.


    In few cases shock waves also have been reported to at least reduce pain and enable walking again. Currently in the process of FDA approval is the injection of collagenase. Recently successful treatment of Ledderhose with cryosurgery (also called cryotherapy) has been reported.

    Cortisone injections, such as Triamcinolone,and clobetasol ointments have been shown to stall the progression of the disease temporarily, although the results are subjective and large-scale studies far from complete. Injections of superoxide dismutase have proven to be unsuccessful in curing the disease while radiotherapy has been used successfully on Ledderhose nodules.

    Ref - Wiki article
     

  6. neo_star

    neo_star Moderator

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    Self assessment on palmar fibromatosis

    in the interest of completeness - I will touch upon palmar fibromatosis with a self assessment question

    Initial therapy for a patient with a functionally significant Duputryren's contracture is


    (A) Physical therapy

    (B) Steroid injection

    (C) Splinting

    (D) Surgery


    Explanation:

    Most nonoperative management techniques will not delay the progression of disease.

    Corticosteroid injections may soften nodules and decrease discomfort associated with them, but are ineffective against cords.

    Splinting similarly has been shown not to retard disease progression.

    Injectable clostridial collagenase has shown promise in clinical trials but has not yet been reported in large or long-term series. It also is not yet commercially available.

    For patients with advanced disease, including contractures of the digits that limit function, surgery is the mainstay of therapy.

    Although rate of progression should weigh heavily in the decision of whether or not to perform surgery, general guidelines are MP contracture of 30° or more and/or PIP contracture of 20° or more.

    Ref - (See Schwartz 9th ed., Chapter 44, Surgery of the Hand and Wrist.)

    Ans D


    Some technical Aspects related to Surgery

    Percutaneous Needle aponeurectomy is the procedure of choice and should be done by a hand surgeon as there may be variations in the anatomy of neuro-vascular structures sec to Dupytren.

    Secondly while performing the release pick a spot over the contracture with loose skin, becos otherwise the skin will not stretch and the results will be poor. Then we will unnecessarily needle in that area further which will lead to skin tearing, further scarring and needless to say further contracture.

    Use smaller gauge needles for digital cords - generally 25 g for digital cords and 23 g for palmar cords.

    only anesthetise the skin becos the patient's perception of nerve irritation is imp to prevent digital nerve injury !!!

    Precaution : Following the procedure the patient is advised to avoid very tight gripping activities as it can recur. Also the patient should be warned that this can recur in the same spot or anywhere else in either hand. Don't give any unrealistic expectations wink)

    Caution : Also if there is scar from previous surgery then this procedure does not hold very good promise and the disturbed neuro-vascular anatomy will be in further danger.

    (-:
     

  7. dr.angela

    dr.angela Bronze Member

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    Lederhose disease
     

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