Baron Guillaume Dupuytren, 1831› Described the condition of palmar fascial

contraction› It is benign fibromatosis of palmer and

digital fascia.

Prevalence – Age, sex, Race, Geographical distribution

Increasing Age Peaks between 40-60 Men > Women 7-15 times White Caucasians of North European descent Genetics unclear autosomal dominant, variable

penetrance Associations 1. Alcohol and liver disease Icelandic cohort study2. Smoking3. Manual work4. Diabetes5. Epilepsy

Strong family history Young patient Bilateral disease with radial

involvement Diffuse dermal involvement Lederhosen – planter fibromatosis Peyronie’ s disease – penile Garrod’s knuckle pads – PIP joints Recurrence and extension

History and examination Palpable nodules , cords, positive table

top test and contracture Dynamic contracture- goniometer

Patients usually have difficulty with tasks such as face washing, hair combing, and putting their hands in their pockets.

Note the site of the nodule and the presence of contractures; bands; and skin pitting, tenderness, and dimpling.

Grade 1 disease presents as a thickened nodule and a band in the palmar aponeurosis; this band may progress to skin tethering, puckering, or pitting.

Grade 2 presents as a pretendinous band, and extension of the affected finger is limited.

Grade 3 presents as flexion contracture

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Thick triangular fascial layer that covers the lumbrical and flexor tunnels between the thenar and hypothenar eminences

Proximally – palmaris longus Distally – Longitudinal bands, called

Pretendinous Bands Bifurcates distally to pass on either

side of the tendons

Exist throughout Superficially they connect the PA to

the dermis Deep fibers are three types1. Septa of Legueu and Juvara2. McGrouther’s Fibers3. Vertical septa between the lumbricals

and flexor tendons

Septa of Legueu and Juvara – well developed fibrous structures arising from the deep surface of PA at the level of the MC head and neck

Pass down to the palmar plate and fascia over the interossei

Most developed distally where they blend with the deep transverse intermetacarpal ligament

They have a sharp proximal border lying 1cm distal to the superficial palmar arch and approx. 1 cm in length

Eight septa, one on either side - four fibro osseous tunnels

Each tunnel has three compartments containing the common neurovascular bundles and the lumbricals

The radial nv bundle of index and the ulnar nv bundle of little are not included

Natatory Ligament (NL, Superficial transverse metacarpal ligament, STML)

Transverse ligament of the palmar aponeurosis (TLPA)

The TLPA differs from the deep transverse intermetacarpal ligament It is a distinct part of the palmar aponeurosis and gives origin to the vertical fibers of L&J

McGrouther – three different insertions for the pretendinous bands

Superficial layer – terminates into the dermis distal to the MCP joint midway between the distal palmar and proximal digital creases

Intermediate layer – passes deep to the natatory ligament and the neurovascular bundles, merges with the lateral digital sheath, Spiral bands of Gosset and may attach to the retrovascular band

Deep layer – passes vertically down at the level of the A1 pulley and terminates in the vicinity of the extensor tendon

Covers the muscles of the hypothenar eminence

Continuous with the ulnar border of the palmar aponeurosis

Merges distally with the tendon of ADM and continues close to the lateral digital sheath

Also attached to the palmar plate of the mcp joint, TLPA, ulnar saggital band while vertical fibers connect to the dermis

Radial continuation of the palmar aponeurosis, much thinner

Skin over thenar aponeurosis more mobile because there are a few vertical fibers connecting it to the dermis

The distal transverse commissural ligament – NL

The proximal transverse commissural ligament - TLPA

The digital fascia holds the skin in position as the fingers or thumbs are moved

1. Grayson’s ligament – midaxial, palmar

2. Cleland’s ligament – thicker, midaxial, dorsal

3. Lateral Digital Sheet – superficial fascia lateral to the nv bundles – NL , Spiral band

4. Retrovascular band – deep to the nv bundles longitudinal fibers

Normal fascial structures in the hand and digits are referred to as bands

Diseased fascial structures in Dupuytren’s are referred to as cords

Palm – Pretendinous cord resulting in MCPJ flexion Does not affect the nv bundles

- Vertical cords can cause pain and triggering

Spiral Band of Gosset

Pretendinous band, its distal continuation, the lateral digital sheet and the Grayson’s ligament May involve the retrovascular band

Gradual contraction of the spiral cord pulls the nv bundle towards the midline which may come to lie transverse to the long axis

Fibroblast proliferation, collagen deposition LUCK, Three Stages Proliferative Stage – increased number of

cells during nodule formation Involutional Stage – longitudinal bands of

collagen fibers – less biologically active Residual Stage – biologically quiescent

disappearance of cells, contracted cords densely packed tough inelastic fibrotic palmar fascia

Anatomical Distribution

Skin Involvement

Contracture

Digital Allen’s Test

Maturity

General Condition

Normally Ulnar

One or more digit

Different stages of involvement

Nodules, Cords, Pits, Skin Shortening

Collagenase – achieved full extension in 90% patients with a single injection and maintained 9 mths after treatment

Radiotherapy, dimethyl sulfoxide, ultrasound, steroids, colchicine, alfa interferon None has shown any significant benefit

Age General Health Motivation Type of hand – Aesthetic , Workman’s H/O CRPS Type of involvement Deformity and progression

Formulation of a plan regarding the management of the skin, involved fascia, joints and extensor apparatus

Management of Skin Surgery does not cure disease, goal is

to release contracture and improve hand function

Spiral cord – The nv bundle is pulled towards the centre and may lie transversely just under the skin

Indications – mp contracture > 30* positive table top test pip contracture > 20* recurrence ..> 20 %Manage skin – fascia (band) – joint

contracture

No incision should cross a flexion crease at right angles on wound closure

Thin potentially avascular flap should be avoided..disease free subcutaneous tissue should left on flap

Dissection start in normal anatomy and proceed distally.

Start cord release in palm and identify NVB then palmer digital skin then digital.

Digital Skin Shortening can be corrected by

Release of skin corrugations by division of the vertical fibers running up to the dermis

Multiple Z plasties Open palm technique Skin replacement

Skin shortage due to dermal contracture

Prophylactic firebreak to separate the ends of contracted fascia

Recurrent disease Electively excised as Hueston’s

dermofasciectomy Skin graft Flap

Fasciotomy Fasciotomy and grafting Extensive

Dupuytren’s --- Firebreak Fasciectomy 1. Segmental2. Complete Longitudinal fasciectomy3. Radical Palmar Fasciectomy4. Dermofasciectomy

Open limited fasciectomy- most popular Dermafasciectomty + STG- firebreak –

for young patients with recurrent disease Mc cash tech – incomplete skin closure,

older pts, 6-8 wks for healing with physiotherapy

Needle fasciotomy- better at mp , 58% recurrence at 3 years

Enzymatic fasciotomy – collagenase, passive motion on 2nd day. 0.58 mg in 0.25 ml ,1/3rd in 3 near by cord area

Gentle passive manipulation Volar plate – check rein ligaments -division

should be performed just proximal to the arterial branch for the vinculum longum, which is preserved.

Accessory collateral ligaments release Flexor tendon sheath release between A2-A4 PIP joint articular changes - arthodesis or

arthroplasty Extensor apparatus – patients with 60 degree

contracture, 80% will show central slip attenuation- ---static extension for 3 weeks Total volar tenoarthrolysis ray amputation

Technique of check rein release. 1, Volar plate. 2, Check rein ligament. 3, Collateral artery. 4, Transverse arterial branch.

Bipolar for hemostasis Under tourniquet control Before closure check for hemostasis If >30* residual pip jt contracture after

fascial excision , then consider pip jt volar release and gentle manipulation.

due to-direct trauma, traction and vasospasm Flex the finger Warm the finger with warm irrigant solution Apply topical papavarine (30 mg/mL) / lignocaine Be patient. Allow the relaxation, warming, and

antivasospasm interventions time to work. The artery may require up to 10 minutes for the restoration of perfusion

If arterial insufficiency persists beyond 10 minutes, explore the digital artery throughout the extent of dissection. Repair of a partial or complete laceration should be performed under the operating microscope. A vein graft may be necessary if undue tension is present

Very important Commenced after early inflammatory

phase (3-5 days) ROM exercises, short periods,

repetitive Splinting, initial static for 2 wks, MCPJ

10-20 deg. Flexion, PIPJ straight, DIPJ free then PIP splint at night – 8-10 wks.

Scar management

17-19 % 0verall Intra operative

Nerve Injury Digital circulationSkin flap Thinning , Button hole

Post operative Haematoma Skin lossInfection Edema Wound Dehiscence

Dupuytren’s Flare – Inflammatory reaction occurring 2-3 wks after the surgeryMore common in women 20 % Acute carpal tunnel syndrome Redness, pain, edema, stiffnessSympathetic blockade, oral steroids, carbamazapine

Reflex Sympathetic Dystrophy – 5 x more common in women (5 %)Pain, edema, stiffness, vasomotor symptomsSympathetic blockade, oral steroids, carbamazapine

Recurrence is the reappearance of disease in the area of previous surgery26-80 %

Extension is the appearance of new disease in an area not subjected to surgery

Common causes of failure 1. Failure to remove all the involved tissues2. Failure to correct PIP joint contractures at

initial surgery

disease recurrence subsequent operation affords a

narrower margin for functional improvement and higher risk to the neurovascular structures

Collagenase modify the underlying disease process

via pharmacotherapeutics and interventional treatments

Communicate bluntly with the patient about potential complications, but place the stastical likelihood in practical terms. (“it is more dangerous to drive on the LIE in the rain than to have a dupuytrens surgery.”)