DUPUYTREN CONTRACTURE

IntroductionDupuytren disease is a proliferative fibroplasia of the

subcutaneous palmar tissue, occurring in the form of nodules and cords, that may result in secondary progressive and irreversible flexion contractures of the finger joints.

Other changes include thinning of the overlying subcutaneous fat, adhesion to skin, and later pitting or dimpling of the skin.

History

Felix plater (1536-1614) – Ist description of palmar fibromatosis.

Henry Cline (1750-1836) – anatomy & recommends surgical release.

Astley cooper (1768-1841) – Repeated trauma, percutaneous fasciotomy.

Guillaume Dupuytrene (1834)- anatomic pathology, C/F, natural history, surgical tech, postop care, response, follow up.

Basic science

Myofibroblast – histologic hallmark of D.CIncrease in type III collagen, total collagen,

lysyl oxidase, glycosoaminoglycans.Increase in cellularity [fibroblast].

Pathogenesis

Local ischemia at the microvascular level increase in fibroblast & related cell types.

Fibroblasts then organize themselves along stress cords deformity.

Ischemia free radicals increased cellsSmoking, HIV, alcohol ability to form free

radicals.Increase Fibroblast vasoconstriction

ischemia. [self perpetuating cycle].

Role of protein factors

PDGF, FGF, TGF-B increased collagen production,

Myofibroblasts more sensitive

NODULES & CORDS:- Major forms of diseased tissues- Two distinct histological tissues

NODULES

Dense cellular collections of myofibroblasts – indicates centers of high met. activity.

LUCK : stages in progression of nodule

1. Proliferative: young nodules with non-stress aligned fibroblasts, grows & fuses to skin

2. Involutional: growth stops – stress alignment of fibroblasts, more collagen tension in N.F fascial H.T nodule cord units

3. Residual: size reduces, aceullar fibrous cords.

CORDS

No myofibroblastsHighly organised collagen structure similar to

tendon.Nodules produce the contraction by pulling the cords

which expand across the jts.

Myofibroblasts found in dermal & epidermal tissue recurrence.

ANATOMY

Normal fascial structures – bands & ligaments.Diseased tissue cords.Nodules – typically occurs between the flexion

creases of MCP & PIP jts.Never over the DIP jt.Palmar fascia pretendinous band deeper

twisting extensions spiral bands.

Distal web space lateral digital sheet Grayson’s lig: fibers volar to NV bundle.Cleland lig: fibers dorsal to NV bundle.

usually spared in disease.

Spiral cord

Diseased PTB, SB,LDS, Grayson lig blends to form SC.

Diseased cord takes a encircling path around the NV bundle.

SC runs dorsal to NV bundle proximally & volar to it distally.

NVB normally travels in a straight line peripherally In Dup.C , it takes a spiral course around the cord,

when cord contracts it is drawn to midline

Pretendinous cord primary contracture of MCP jt Lateral digital cords contracture of DIP jtIsolated digital cords in addition to central, spiral or

retrovascular cords PIP jt contracture.

CLINICAL FEATURES

DEMOGRAPHICS

- Autosomal dominant trait. [variable penetrance]

- Age at presentation & severity of disease

- scandinavian, Britain, Australia – more common

- middle east, Greece, orient – virtually unknown.

M : F [7:1]After 40 yrs. [5-7 th decade]Tender nodule or progressive palmar cord

development.Skin pitting & nodule formation near distal palmar

crease – early findings.Ring & little fingers usually first digits Progression of disease is unpredictable.Remission & exacerbationsWomen disease is less severe.B/L in 45%, but rarely symmetrical.

Contributing factors

Trauma & type of manual laborDiabetics, epileptics, alcoholicsDupuytrene diathesis.

DUPUYTRENE’S DIATHESIS

Spectrum of physical findings that is present in patients with strong gene expression.

Earlier presentation.[20 -30s]Very aggressive, multiple digits & B/L handGarrod’s nodes – knuckle padsLederhose’s disease – plantar fibromatosisPeyronie’s disease – penile fascial involvement.Poor surgical outcome.

GRADES

Grade I – thickened nodule & band in PA skin tethering & puckering – full movt.

Grade II – peritendinous bands involved extension of fingers limited.

Grade III – flexion contracture.

Disease Recurrence

Controlled at gene levelSurgical excision of affected tissues won’t cure.Improves the hand function by reducing the

contracture.More common in young pts & in Dupuytrene’s

diathesis.New foci or from residual disease.Myofibroblast persisting in the skin & SC.

NON OPERATIVE TREATMENT

Creams, lotions and steroid inj [tender nodules], physical therapy all are doubtful

Most valid – education of both patients & primary physicians.

OPERATIVE INDICATIONS

TABLE TOP TEST:

- Guideline for considering operation

- positive when can no longer place the palm flat on a hard surface.

- Pts themselves can check the progression.

- correlates with MCP contracture of >30-40*.

HUESTON TABLE TOP TEST

MCP jt contracture 40* or more Treatment of other digits on the same hand should

be considered when their MCP cont are 20-30* or more.

PIP jt release if PIP jt contracture > 30*.Important to distinguish true PIP jt cont from

apparent one. [spiral cord]MCP jt cont is measured with PIP jt held in

extensionPIP jt cont is measured with MCP jt in flexion.Patients preference.Educated – postop comp,rehablitation,recur.

OPERATIVE TREATMENT

Several Procedures available, differ inManagement of palmar fasciaTreatment of volar skinDesigns of incision.

Management of P.F

Radical fasciectomySelective fasciectomySegmental fasciectomyFasciotomy.

Selective fasciectomy

Most commonly used.Resection of all diseased fascia in palm & finger, adj

normal fascia is left.Chance of recurrenceBest correction, with acceptable rehabilitation &

complication.

Segmental fasciectomy

Removal of one or more segments of diseased fascia.Partial or complete correction.

PERCUTANEOUS FASCIOTOMY:

- Modest correction in less severe contracture.

- partial correction of severe contracture

- in debilitated & very elderly Pts.

- Unable to comply with rehablitation.

Management of volar skin

Direct closure after fascial excision.Skin excision followed by full thickness skin grafting.Open tech, volar skin is left open to close

subsequently by wound contraction.

Direct closure

With or without skin flap rearrangementsPrimary wound healingNo need for skin graft.Simple postop wound management.Disadvantage:

- hematoma formation,

- skin flap necrosis

- need for skin flap rearrangements to provide length.

Skin grafting

Hueston Believes that palmar skin has modulating effect on

underlying palmar fascia.Recurrence is rare with full thickness SG.Doesn’t control the extension of disease beyond the

grafted areas.DISADVANTAGES;

- Graft loss

- hematoma formation

- prolonged immobilization for graft incorporation

- stiffness

- altered sensibility over the grafted areas

- altered wear characteristics.

Open wound tech

McCashTransverse incision in palm at the level of MPC

combined with addl incisions in fingers.Transverse incision is left open.Covered by non-adherent dressing.Once motion is initiated, covered with dry dressingWound contracts to its precontracture length.

ADV:

- lower complication rate. [hematoma, wound edge necrosis]

- early postop Pt comfort.

- post p infection is rare.DISADV:

- Inconvenience to pt during 3-5 wks

INCISIONS

Longitudinal midline incision with Z-plasty closure.Brunner zigzag incisionZigzag incision with V-Y advancement.

BRUNNER INCISION

Preferred in most ptsSimple to plan reliable in healing & appearanceSevere cont the palmar part is covered with SG or It is made transverse incisionManaged with left open tech.

Amputation

If flexion contracture of the PIP joint, especially of the little finger, is severe and cannot be corrected enough to make the finger useful.

In severe recurrent PIP jt contracture.[ 90*]A dysvacular digitPainful or insensate digitPatience preference.

PIP jt fusion

Severe flexion contracture [>90*]Recurrent diseasePIP jt arthritisInability or unwillingness to comply with required

postop therapy.

POST OPERATIVE treatment

GOALS

- Maintain the correction

- reduce postop edema

- scarring

- restore preoperative flexion & grip strength.Pt compliance.

Therapy begins 2-5 days postop.Volar forearm based splint with wrist in neutral &

fingers in extension as much as possible. thumb is splinted in extension to minimize web-space contracture.

To start immediate active ROM ex of flexion & extension.

Passive stretching as per pain tolerance

Attention to be paid to PIP jt [to overcome collateral ligament & capsular contracture.]

Jt block ex required to regain DIP jt flexion [esp if hyperextension was present preop]

2nd postop week, splinting during day time is weaned.Encourage the use of handNighttime use of splint continued up to 6 mon

Scar management

-Massage with silicone gel

STRENGHTHENING EXERCISES:

- begin once wound gets healed

- 3 wks after primary closure

- 4 wks after for SG

- 6 wks after open palm tech.

Complications

Intraop: inadvertent division of digital nerve.

- loupe magnification

- identify the nerves before start cutting.

- not to excise any tissue until digital nerve has been identified DN is identified on both sides of excision zone.

Hematoma formation.Wound healing difficulties.

Vascular compromise of digits

- resurgeries

- do digital allen test before surgery

- necessary to accept less deformity correction in favour of blood flow to aff. digits.

FLARE REACTION [ RSD]

-1-8%

- More common in pts with simultaneous CTS release

- female

- early recognised & immediate treatment.

Recurrence

2 - 63 % cases

full thickness grafts better results.