1.
DUPUYTREN
CONTRACTURE

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.
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.
Basic science
Myofibroblast – histologic hallmark of D.C
Increase in type III collagen, total collagen,
lysyl oxidase, glycosoaminoglycans.
Increase in cellularity [fibroblast].

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Contributing factors
Trauma & type of manual labor
Diabetics, epileptics, alcoholics
Dupuytrene diathesis.

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.
GRADES

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.
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.
NON OPERATIVE TREATMENT
Creams, lotions and steroid inj [tender nodules],
physical therapy all are doubtful
Most valid – education of both patients & primary
physicians.

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*.

22.
HUESTON TABLE TOP TEST

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.
OPERATIVE TREATMENT
Several Procedures available, differ in
Management of palmar fascia
Treatment of volar skin
Designs of incision.

25.
Management of P.F
Radical fasciectomy
Selective fasciectomy
Segmental fasciectomy
Fasciotomy.

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.
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.
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.
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.
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.
- hematoma formation
- prolonged immobilization for graft incorporation
- stiffness
- altered sensibility over the grafted areas
- altered wear characteristics.

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.
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.
INCISIONS
Longitudinal midline incision with Z-plasty closure.
Brunner zigzag incision
Zigzag incision with V-Y advancement.

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.
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.
PIP jt fusion
Severe flexion contracture [>90*]
Recurrent disease
PIP jt arthritis
Inability or unwillingness to comply with required
postop therapy.

38.
POST OPERATIVE treatment
GOALS
- Maintain the correction
- reduce postop edema
- scarring
- restore preoperative flexion & grip strength.
Pt compliance.

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.
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.
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.
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.
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.
Recurrence
2 - 63 % cases
full thickness grafts better results.