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Dupuytren’s Disease 

A fibroproliferative disorder of the hand characterized by the development of new tissue in the form of nodules and cords resulting in a progressive contracture of the fingers into the palm.
• Most common in men over 60 who are Scandinavian, Irish or eastern European 

History 
First description credited to Felix Plater (1614, Basel Switzerland). 
  • Henry Cline (1808, London)described typical palmar fibrosis and flexion contractures and recommended surgery. 
  • Astley Cooper (1822) also described finger contractures in A Treatise on Dislocations and Fractures of the Joints 
  • Guillaume Dupuytren (1777-1835, Paris) published a description of 2 patients with palmar fibromatosis in 1834 

Demographics 
  • May be autosomal dominant with variable penetrance or sporadic (approximately 10% have a positive family history)
    • Mainly Scandinavia and Great Britain 
    • Rarer in Europe further south
    • Common in Australia due to British/ Irish 
    • virtually unknown in Greece, Middle East and orient • though Indians living in the UK have developed disease 
    • therefore possible environmental component 

Dupuytren’s Diathesis 
Spectrum of physical findings in patients with particularly strong gene expression • Present earlier (20’s or 30’s)
• Very aggressive cord development
• Multiple digit and bilateral 
• Garrod’s nodes (knuckle pads)
• Lederhose’s disease (plantar fibromatosis)
• Peyronie’s disease (penile fascia involvement) 

Significance
• High risk of poor surgical outcome/ early recurrence 
• Complications • Longer rehab 

Pathology of nodules and cords 
  • Nodules and cords are pathological (abnormal) structures 
  • Distinct histological features 
    • Nodules are dense cellular collections of myofibroblasts 
    • The myofibroblast in the nodule accounts for active contraction 
    • Nodules produce flexion contractures by pulling through cords that have extended 
      past joints 

  • Recurrence after surgery may be 2 to myofibroblast populations that have migrated into 
    adjacent palm dermis and epidermis 

    Anatomy 
    • Palmar aponeurosis is a triangular thin sheet of fascial tissue organized distally into pre- tendinous bands (normal anatomic structures) 
    • Forms a 3D fibrous tissue continuum which acts as a framework for longitudinally running structures 
    The distal longitudinal fibres can be divided into 3 layers
    ! 1. Superficial; insert into the skin over the distal palm 
    • Insertion progressively more distal from radial to ulnar
    ! 2. Spiral fibers either side of the flexor tendon deep to the neurovascular bundle to the lateral digital sheet 
  • 3. Deep longitudinal fibers pass deeply either side of flexor tendons and MCP jts 

Cord Contraction 
• the Central cord follows layer 1 but passes more distally • Follow longitudinal pretendinous fibers
• Attaches to deep dermis and middle phalanx 
• the Lateral cord is from the natatory ligament to the lateral digital sheet • does not usually cause PIP flexion contracture 
• BUT on ulnar LF attaches to abductor cord and in this case can cause severe contracture 
• the Spiral cord is from the longitudinal pretendinous fibers and follows layer 2 
  • Through the spiral cord of Gosset to the lateral digital sheath 
  • Attached to P2 via Grayson’s ligament 
    The spiral cord contracts and displaces the neurovascular bundles towards the midline and superficially 
    • making them prone to injury during surgery or injections 

    Clinical Presentation 
    • Men to women >7:1 
  • Less severe or atypical in women 
  • Nodule forms first but may disappear as disease progresses 
    or may present when tender nodule or noticed
    Often present late with severe joint restriction if the disease is completely painless (common)
    Often referred as trigger finger or “joint stiffness” 
  • Progression unpredictable 
  • Trauma may be a stimulus for progression 

    Table top test of Hueston – place hand and finger flat on table
    o If your hand can go flat then surgery is usually not indicated 
    - Correlates with MCP (knuckle) joint contracture>30 deg Functional impairment – affected finger gets in the way of: 
    o Washing your face/combing hair o Putting your hand in your pocket o Racquet sports or golf 

    Treatment 
    Non-operative 
    -Education and reassurance 

  • Disease is often mild and may never require surgical treatment 
  • Progression of the disease is very difficult to predict 
  • Stretching, massage or exercises are not helpful and make no difference to outcome 
  • A steroid injection may help a tender nodule (not useful in cord disease) or for knuckle 
    pads 

• Collagenase (Xiaflex) injection dissolves the cord and may be useful in early disease 

Operative 
• Needle fasciotomy 
  • performed under Local Anaesthetic (LA) to divide cords 
  • simple and useful in early contractures with quick recovery but may get rapid recurrence 

• Percutaneous fasciotomy
• cords are cut through small incisions (LA) • similar indications to needle fasciotomy 

• Open surgery (selective fasciectomy) 
  • aim is to excise the diseased fascia to release contractures
    • preserving main nerves and vessels
  •  • maintaining full flexion of the fingers (avoiding stiffness) 
  • combination of longitudinal and zig-zag (Brunner) incisions used with Z plasties to lengthen skin wounds (moves skin from the side to gain length)! 
  • +/- skin grafts
    • may decrease recurrence by bringing in normal skin
    • BUT potentially slows rehabilitation resulting in more stiffness AND altered sensation, poorer wearcharacteristics (to normal skin) and poorer cosmesis 
     I use in severe disease/ Dupuytren’s diathesis or in revision (2nd) surgery 

  • PIP (proximal finger) joint release 
    • controversial 
    • if the joint is still bent after cord excision the joint is often released 
    • BUT may result in significant stiffness 
    • AND difficult to maintain initial results 
    • therefore I only perform joint releases if a severe contracture persists after cord excision; it is more important to be able to bend the finger easily after surgery than have a perfectly straight finger 
Surgical risks 
• long term recurrence is about 50%
• skin/ flap necrosis - usually heals with dressings only • Nerve/ vessel injury - more likely with severe disease •Complex Regional Pain Syndrome (CRPS) 
  • difficult to predict and approximately 5% will develop 
  • results in stiffness and often a poor result 
  • Vitamin C (daily for 6 weeks) may decrease the risk but using and moving the hand with the guidance of hand therapy is more important 

    Post-operative management/ rehabilitation 
    • Hand therapy is extremely important in achieving a good result
    • night splint (maintaining extension) for 4- 6 months
    • out of plaster/ splints and moving, using the hand during the day in the first week • swelling/ oedema control helps decrease the resistance to movement (and pain) • wound and scar management