Secretan Syndrome

Secretan Syndrome

Secretan syndrome, also known as posttraumatic edema syndrome, is caused by a peritendinous fibrosis that occurs after trauma to the dorsum of the hand.

Often, the trauma is seemingly minor, such as hitting the back of the hand on the corner of a desk. Initially, the swelling and tenderness may be attributed to the trauma, but instead of improvement with time, the dorsum of the hand becomes more indurated with the edema becoming brawny.

Without treatment, peritendinous fibrosis and an almost myxedematous hardening of the soft tissues of the dorsum of the hand occur. Similar to the pain of Dupuytren contracture, the pain of Secretan syndrome seems to burn itself out as the disease progresses.

What are the Symptoms of Secretan Syndrome

Brawny edema with associated loss of extensor function of the hand after seemingly minor trauma is the sine qua non of Secretan syndrome.

In contrast to reflex sympathetic dystrophy, which can mimic Secretan syndrome, no sudomotor, vasomotor, or trophic nail changes occur, although the skin changes can appear identical to the skin changes of reflex sympathetic dystrophy.

How is Secretan Syndrome diagnosed?

Plain radiographs are indicated in all patients who present with Secretan syndrome to rule out underlying occult bony pathological processes. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, uric acid level, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated.

Magnetic resonance imaging (MRI) and ultrasound imaging of the hand will help confirm the diagnosis and also are indicated if joint instability, infection, or tumor is suspected. Electromyography is indicated if coexistent ulnar or carpal tunnel syndrome is suspected. Injection of the areas of fibrosis provides improvement of the pain and disability of this disease if implemented early.

Differential Diagnosis

Coexistent arthritis, gout of the metacarpal and interphalangeal joints, and tendinitis also may coexist with Secretan syndrome and exacerbate the pain and disability of Secretan syndrome.

Reflex sympathetic dystrophy may manifest in a similar clinical manner but can be distinguished from Secretan syndrome because the pain of reflex sympathetic dystrophy responds to sympathetic neural blockade and the pain of Secretan syndrome does not. Given the uncommon nature and unusual presentation of this syndrome, factitious pathoetiology should be considered.

How is Secretan Syndrome treated?

Initial treatment of the pain and functional disability associated with Secretan syndrome should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold also may be beneficial. For patients who do not respond to these treatment modalities, an injection of a local anesthetic and steroid into the areas of the peritendinous fibrosis may be a reasonable next step.

The use of physical therapy, including gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique. Vigorous exercises should be avoided because they would exacerbate the patient’s symptoms.

Complications

Injection of the peritendinous fibrosis responsible for Secretan syndrome is a relatively safe technique if the clinician is attentive to detail. Such tendons may rupture if directly injected, and needle position should be confirmed outside the tendon before injection to avoid this complication. Another complication of this injection technique is infection. This complication should be exceedingly rare if strict aseptic technique is followed. Approximately 25% of patients report a transient increase in pain after this injection technique, and patients should be warned of this possibility.

Clinical Pearls

This injection technique is extremely effective in the treatment of pain and dysfunction secondary to Secretan syndrome. Coexistent arthritis, tendinitis, and gout also may contribute to the pain and may require additional treatment with more localized injection of a local anesthetic and depot steroid. Given the uncommon nature and unusual presentation of this syndrome, factitious pathoetiology should be considered.

This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator. The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection. The use of physical modalities, including local heat, massage, and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique. Vigorous exercises should be avoided because they would exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.