Detail case discussion of dupuytren's contracture including clinical aspect and theoretical aspects. Dupuytren's is progressive superficial palmar fibromatosis, involves superficial palmar fascia of hand and causes contracture and severe disability in advance disease. Case discussion done under Platiquest channel.

1. DUPUYTREN’S CONTRACTURE
CASE DISCUSSION
Presenter: Dr. Sudhir Navadiya, (3rd Yr M.Ch)
B. J. Medical College, Ahmedabad
Mentor: Prof Dr. P. Lakshmi, M.Ch
Prof. of Plastic Surgery,
Osmania Medical College,
Hyderabad

2. Guide: Prof. Dr. M F Shaikh,
Prof. Dr. Jayesh Sachde,
BJMC, Ahmedabad
Plastiquest Mentor: Prof. Dr. Palukuri Lakshmi,
Osmania Medical College, Hyderabad
Guest faculty: Dr. Sheeja Rajan,
Gov. Medical College, Kozhikode
Moderators: Dr. Sundeep Vijayaraghavan
Dr. G. S. Radhakrishnan

3. • 58 year old gentlemen, Mohan Kumar
from Ahmedabad, right handed and
manual laborer
• Came with chief complaint of:
- Unable to straight a both hand
little finger since 1 year
- Deformity in bilateral little finger
since 6 month.

4. History of present complaints
• As per patient self, he was apparently alright before 1
year then he developed difficulty in straitening of little
finger. initially in right hand and few weeks later in left
hand. But he had not gave any attention to that.
• That is increased gradually and he had developed a
deformity of little finger in both hand up to present
status.

5. • No history of trauma or burns
• No history of epilepsy and medication
• No history of any medical treatment or injection therapy or
surgery for the same
• No history of weakness in any hand movement
• No history of similar thickening or band in sole or penis
• Patient is smoker since 35 years taking 4-5 bidis daily
• No history of alcoholism
• No history of diabetes
• No similar history in family

6. General Examination
• Patient is normally built, conscious, co-operative and
well oriented to time, place and person.
• Vitals :
Pulse is 78/min, BP is 130/78 mmHg and RR is 16/min
No pallor, icterus, clubbing, cyanosis, dilated neck vein
or lymphadenopathy.

7. Local Examination :
Inspection:
• Patient’s is sitting comfortably with both
shoulder in adduction, elbow flexion, wrist
and finger in neutral position.
• Examined under proper light with both
parallel in supine and prone.
• Narrowing and mild cupping of right palm
present with reduced palmar arch.
• Right and left hand little finger flexion
deformity at MCP, PIP and DIP joint.

8. • Right little finger is in adduction.
• Left little finger is in abduction.
• Single contracture band in both hand little
finger extending from distal palmar crease to
middle phalanx.
• Two pits are present in both hand over base
of proximal phalanx of little finger distal to
distal palmar crease.

9. • Hueston’s table top test: Positive in both
hand little finger
• Hugh Johnson sign (Distortion of skin crease
can appear as Deepening or widening of skin
crease) – more on right hand than left hand.
• Dorsal skin normal.
• No scar of any previous surgery
• Planter and Penile area normal

10. Palpation:
• Findings of inspection are confirmed with
pits.
• Right Palm narrowing with cupping present
with reduced palmer arch on right hand.
• No local tenderness or raise in temperature.
• Skin is fixed with underlying cord in both
hand over base of little finger and distal
palmer crease area.
• Skin shortening is present with contracture
over Base of little finger in both hand.

11. • Contracture band is present extending from
distal palmer crease up to middle phalanx in
both finger and is fixed to skin, blanching is
present on passive finger extension in both
hand.
• No tenderness on tapping the band area.

13. • In both hand,
 Active & passive flexion in MCP, PIP and DIP
joint is equal and in full range
• In right hand little finger, extensor lag is present at
 MCP – 30 degree PIP – 35 degree
 DIP – 15 degree
• In left hand little finger, extensor lag is present at
 MCP – 30 degree PIP – 30 degree
 DIP – 15 degree
• Adduction deformity present in right little finger and
Abduction deformity in left little finger.
• MCP, DIP and PIP joints are supple and mobile

14. • Abduction and adduction in remaining four digits are normal in both hand.
• Range of all movements at all joints of rest all fingers of both hands - Normal
• Tubiana grade 2 in Right hand (80°) Grade 2 in Left hand (75°)
• Short Watson sign: Present (Soft palpable fullness immediately adjacent to
the cord at level of MCP Jt. – displacement of NVB)
• Distal sensation normal
• Capillary refill is normal
• Muscle power is normal
• Ulnar and radial pulse are palpable.
• No peripheral nerve thickening.
• Planter area and penile area both are normal.

15. Diagnosis:
• Dupuytren’s contracture deformity, involving both
hand little finger with Tubiana grade 2, with
reduction in right palmer arch, Adduction
in right little finger and abduction deformity in left
little finger.
• MCP, PIP, DIP flexion – Pre-tendinous & Central
cord.
• DIP flexion – Lateral cord, retro-vascular cord
• Right Palmer Arch- Natatory cord
• Adduction –Natatory cord

16. Differential Diagnosis:
• Post traumatic/Burns Contracture
• VIC
• Camptodactyly
• Leprosy
• Trigger finger
• Intrinsic Joint Ankylosis
• Spastic Contracture

17. Investigation:
• Clinical diagnosis & History is enough to diagnose the
condition.
• Routine investigation for pre operative fitness
• X ray Hand
• Doppler study to localizes Neurovascular bundle migration.

18. Objective:
• Correction of deformity
• Reducing disability
• Restoring hand function.

19. • My plan is Regional partial
Fasciectomy as patient having PIP
& DIP joint involvement with
flexion contracture with following
skoog incision.
• Transverse incision in right palm if
needed.

20. Post Op Protocol:
• Physiotherapy started by post op day 5 once edema and
pain settle down.
• If residual contracture is still present, dynamic spilt is applied
volar extension splint is applied.
• Active and passive range of motion started by one week.
• By the end of the second week, full passive range of motion is usually
achieved, at which time sutures are removed and more aggressive
therapy can started.
• Nighttime splinting is continued for 6 months after surgery, and
weekly monitoring of joint range of motion is provided by the
surgeon.

21. Option for treatment:
• Non Surgical Modality:
⁃ Needle Fasciotomy +/- Fat grafting
⁃ Injection Therapy: Corticosteroids, Collagenase (Enzymatic)
⁃ Others: Extension splinting, Ultrasound, Radiotherapy, Dimethyl
Sulfoxide, Vitamin E, Methyl hydrazine, Allopurinol, Colchicine,
Interferon Gamma/Alpha
• Surgical Modality:
⁃ Percutaneous fasciotomy - Open Fasciotomy
⁃ Local/segmental Fasciectomy - Regional Fasciectomy
⁃ Radical Fasciectomy - Dermatofasciectomy

23. HISTORY
• 1614 – Plater – Clinical description
• 1777– Cline – Suggested Fasciotomy
• 1822 – Astley Cooper – Percutaneous Fasciotomy
• 1831 – Dupuytren’s - Open Fasciotomy
• 1834 – Goyrand – Fasciectomy
• 1906 – Keen – Radical Fasciectomy
• 1957 – De Seze - Steroid injection & needle fasciotomy
• 1959 – Luck – Histology staging
• 1963 – Hueston – Diathesis concept
• 2009 – Degreef – Tamoxifen
• 2010 – Hurst – Collagenase FDA approval

27. • What is Dupuytren’s Disease?
 Progressive proliferative Superficial Palmar Fibroplasia called
Dupuytren’s Disease.
• What are responsible Cellular factor for Dupuytren’s?
 Myofibroblasts & Fibroblasts  Vascular Ischemia, Tissue level
microvascular ischemia  Promote more fibroblast  Vicious Cycle
Initiating Events: Trauma, focal ischemia, mechanical stress
• Why more common in male?
 Male have 7 time more common than female Fibroblast having
androgen receptor which leads to more common in male More
laborer work

28. • Growth Factor associated with Dupuytren’s Disease?
 TGF Beta, FGF are stimulatory and PDGF are inhibitory
• Molecular component in various stages?
 Nodules – Dense collection of Myofibroblats
 Cord – Highly organized collection of collagen similar to tendon,
Myofibroblasts
 In Early Active Phase – Collagen lll > l
 In involution Phase – Collagen l > lll
 MaFB gene may be involved – Muscular Aponeurotic Fibro
Oncogene B
 Histologically thinning of dermal skin and absence of sweat glands.

29. • Staging of Dupuytren’s Disease:
Histological Staging: Luck’s
 Proliferative Phase – Nodule formation, increased Myofibroblasts &
collagen lll
 Involution Phase – Nodular thickening with early contracture,
Myofibroblasts reorientation
 Residual Phase – Decreased Myofibroblasts with collagen l > lll
Tubiana Grading: Composite joint flexion contracture of MCP+PIP+DIP
 Grade 0 – No Contracture
 Grade N – Nodule only
 Grade l – 0 to 45degree
 Grade ll – 45 to 90 degree
 Grade lll – 90 to 135 degree
 Grade lV – more than 135 degree

30. • Areas Involved with Dupuytren’s Disease other than Palm?
 Garrod’s Pad – Dorsum of PIP joint involved (Knuckle Pad)
 Lederhose Disease – Planter foot
 Peyronei's Disease – Penis
 Other involvement also seen occasionally: Auricular Concha, TFL,
Tendoachillis
• What is deep Fibromatosis?
 Sometime deeper myofascial structure involved in progressive
fibromatosis disease it is called deep fibromatosis.
 Two type of involvement seen.
Extra-abdominal – Arm, chest and Para spinal region
Abdominal – Abdominal wall: Desmoids tumor
Intra-Abdominal: Mesentery, Pelvis, Retroperitoneum

31. • Which hand functions are compromised in Dupuytren’s Disease?
- Hand Shaking
- Fitting of Gloves
- Difficulty in keeping hand in Pocket
- Difficulty in Grasping large objects
- Washing Face as finger pokes to eye.
• Most Commonly Involved Joints in Dupuytren’s Disease?
MCP > PIP > DIP(Rarely)

32. • Differential Diagnosis for Dupuytren’s Disease?
 For Nodules:
Callosity
Hyperkeratosis
Ganglion
Giant cell tumor Inclusion Cyst Fibroma/Fibro sarcoma
Foreign body
Nodular fasciitis
 For Contracture:
Post Burn Contracture
Post trauma Contracture
VIC
Spastic Contracture
Camptodactyly

33. • Commonly involved Bands in Dupuytren’s Disease?
At MCP & PIP Level: Pre-tendinous Band
Spiral band
Lateral Digital Sheet
Grayson’s Ligament
Central Cord
At DIP Level: Retro vascular Cord/Band Lateral Cord/band
Web Space Adduction : Natatory Ligament
Little finger Abduction: Abductor Digiti Minimi
• Which Structure are not involved in Dupuytren’s Disease?
Cleland’s Ligament
Transverse superficial palmar Ligament and
Occasionally Septa of legueu and Juvara is spared

34. • Which Structure Forms Spiral cord?
 Pre-tendinous Band Spiral band
 Lateral Digital Sheet Grayson’s Ligament
• Importance of Spiral cord?
 Spiral cord causes displacement of Neurovascular Bundle (NVB)
medially and superficially, which can easily damage during surgery,
even during incision itself.
• How to avoid NVB injury during surgery?
 NVB is deeper located in palm proximal to distal palmar crease. So,
during surgery it is identify first at MCP joint and proximal to it and
traced it distally as dissection proceed.

35. • If MCP & PIP joint both involved which joint is priority and Why?
 PIP joint is priority for surgical release.
 Because in flexion position collateral ligaments MCP joint is
and taut, while in PIP flexion position collateral ligament is grossly
contracted. So, if surgical release is delated, then PIP joint will go in
permanent capsular contracture deformity.
• Diagnostic Protocols:
 Dupuytren’s is disease of diagnosis by history and examination only.
X-ray to rule out joint condition, Doppler to localize displaced NVB.

36. • Diagnostic test for Dupuytren’s contracture just by inspection?
 Table top test: Patient keep hand flat on edge of table, normally
hand to be flat. If angle of more than zero degree, than test is
positive
• What is Dupuytren’s Diathesis?
 Dupuytren’s diathesis refers to Biological severity of disease. More
the diathesis factor, more chance of severe disease and
 Factors:
- Young Age - Male Gender
- Positive Family history - Bilateral hand involvement
- Dorsal Garrod’s nodules - Lederhose Disease
- 1st digit involvement - More than 2-digit involvement

37. • GOAL of Surgery in Dupuytren’s Disease?
 Deformity correction, Disability reduction, Restoration of hand
• Indication of Surgery in Dupuytren’s Disease?
 Rapid progression
 Painful nodules
 Strong family history
 PIP contracture of any degree MCP contracture of >30 Degree
Relative indications:
Functional adduction deformity 1st web space
Little finger adduction contracture
Contracture with maceration in Palm
Non-resolving secondary tenosynovitis
Secondary palmar nodules

38. • Incisions for Dupuytren’s contracture release?
 Skoog Incision – straight line with broken Z Plasty
 Brunner Incision – Zig Zag incision
 Palmen Incision – Incision with multiple V-Y Plasty
 McCash Incision – Along distal palmar crease, Skin incision left
for secondary healing
• Hugh Johnson sign: Distortion of skin crease appear as Deepening or
widening of skin crease.
• Short Watson sign: Soft palpable fullness immediately adjacent to the
cord at level of MCP Jt. Indicates displacement of NVB.

39. • Options for Dupuytren’s Management?
Non-Surgical Modality:
- Needle Fasciotomy +/- Fat grafting
- Injection Therapy: Corticosteroids, Collagenase (Enzymatic)
- Others: Extension splinting, Ultrasound, Radiotherapy, Dimethyl
Sulfoxide,
- Vitamin E, Methyl hydrazine, Allopurinol, Colchicine, Interferon
Gamma/Alpha
Surgical Modality:
- Percutaneous fasciotomy - Open Fasciotomy
- Local/segmental Fasciotomy - Regional Fasciotomy
- Radical Fasciectomy - Dermatofasciectomy

40.  Steroid Injection therapy work for nodular disease only
 Collagenase works also for cords.
 Dermatofasciectomy needed in High diathesis score, Multiple &
severe recurrence, Insufficient skin with diffuse involvement.
• How to correct residual FFD of PIP joint after Fasciectomy?
After excision of involved fascia, additionally following steps can be
taken;
 Release of flexor sheet
 Check rein ligament release
 Collateral ligament release
 Volar capsulotomy
 Lastly, wedge osteotomy, PIP arthrodesis or amputation

41. • Recurrence rate in Dupuytren’s Disease?
 With percutaneous/Injection procedure: 50-58 %
 With Open surgical procedure: 32-40 %
• Complications of Injection therapy?
 Steroids: Dermal atrophy, Skin depigmentation, Tendon rupture
 Collagenase: Pain, localized skin reaction, edema, ecchymosis, skin
tears, tendon rupture.

42. • Late postoperative complication?
 CRPS: Complex Regional Pain Syndrome, presented moths
later with Pain, Allodynia, Redness edema, suggest
vasomotor instability.
 Recurrence:
Early in 3 month – Mostly residual 2° Pathology
Progressive in 3 to 12 Month – Residual 1° pathology, inadequate
resection Late after 1 year – True recurrence, New Disease

43. • Post Op Protocol:
• Physiotherapy started by post op day 5 once edema and pain settle
down.
• If residual contracture is still present, dynamic spilt is applied
otherwise volar extension splint is applied.
• Active and passive range of motion started by one week.
• By the end of the second week, full passive range of motion is
achieved, at which time sutures are removed and more aggressive
therapy can be started.
• Nighttime splinting is continued for 6 months after surgery, and
weekly monitoring of joint range of motion is provided by the
surgeon.

44. Thank You