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Dupuyterene contracture

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Dupuyterene contracture

  2. 2. Introduction Dupuytren 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.
  3. 3. 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.
  4. 4. Basic science Myofibroblast – histologic hallmark of D.C Increase in type III collagen, total collagen, lysyl oxidase, glycosoaminoglycans. Increase in cellularity [fibroblast].
  5. 5. 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 cells Smoking, HIV, alcohol  ability to form free radicals. Increase Fibroblast  vasoconstriction  ischemia. [self perpetuating cycle].
  6. 6. 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
  7. 7. 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.
  8. 8. CORDS No myofibroblasts Highly 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.
  9. 9. 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.
  10. 10. 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.
  11. 11. 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
  12. 12. Pretendinous cord  primary contracture of MCP jt Lateral digital cords  contracture of DIP jt Isolated digital cords in addition to central, spiral or retrovascular cords  PIP jt contracture.
  13. 13. 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.
  14. 14. 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 & exacerbations Women disease is less severe. B/L in 45%, but rarely symmetrical.
  15. 15. Contributing factors Trauma & type of manual labor Diabetics, epileptics, alcoholics Dupuytrene diathesis.
  16. 16. 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 hand Garrod’s nodes – knuckle pads Lederhose’s disease – plantar fibromatosis Peyronie’s disease – penile fascial involvement. Poor surgical outcome.
  17. 17. GRADES
  18. 18. 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.
  19. 19. Disease Recurrence Controlled at gene level Surgical 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.
  20. 20. NON OPERATIVE TREATMENT Creams, lotions and steroid inj [tender nodules], physical therapy all are doubtful Most valid – education of both patients & primary physicians.
  21. 21. 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*.
  23. 23. 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 extension PIP jt cont is measured with MCP jt in flexion. Patients preference. Educated – postop comp,rehablitation,recur.
  24. 24. OPERATIVE TREATMENT Several Procedures available, differ in Management of palmar fascia Treatment of volar skin Designs of incision.
  25. 25. Management of P.F Radical fasciectomy Selective fasciectomy Segmental fasciectomy Fasciotomy.
  26. 26. Selective fasciectomy Most commonly used. Resection of all diseased fascia in palm & finger, adj normal fascia is left. Chance of recurrence Best correction, with acceptable rehabilitation & complication.
  27. 27. 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.
  28. 28. 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.
  29. 29. Direct closure With or without skin flap rearrangements Primary wound healing No need for skin graft. Simple postop wound management. Disadvantage: - hematoma formation, - skin flap necrosis - need for skin flap rearrangements to provide length.
  30. 30. 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
  31. 31. - hematoma formation - prolonged immobilization for graft incorporation - stiffness - altered sensibility over the grafted areas - altered wear characteristics.
  32. 32. Open wound tech McCash Transverse 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 dressing Wound contracts to its precontracture length.
  33. 33. 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
  34. 34. INCISIONS Longitudinal midline incision with Z-plasty closure. Brunner zigzag incision Zigzag incision with V-Y advancement.
  35. 35. BRUNNER INCISION Preferred in most pts Simple to plan reliable in healing & appearance Severe cont the palmar part is covered with SG or It is made transverse incision Managed with left open tech.
  36. 36. 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 digit Painful or insensate digit Patience preference.
  37. 37. PIP jt fusion Severe flexion contracture [>90*] Recurrent disease PIP jt arthritis Inability or unwillingness to comply with required postop therapy.
  38. 38. POST OPERATIVE treatment GOALS - Maintain the correction - reduce postop edema - scarring - restore preoperative flexion & grip strength. Pt compliance.
  39. 39. 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
  40. 40. 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 hand Nighttime use of splint continued up to 6 mon
  41. 41. 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.
  42. 42. 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.
  43. 43. 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.
  44. 44. Recurrence 2 - 63 % cases full thickness grafts better results.