dupuytren contracture and its anatomy of hand with pathology and intervention

1. Dupuytren’s Disease

2. Dupuytren’s Disease:
–thinning of the overlying subcutaneous fat
–adhesion to skin
–and later pitting or dimpling of the skin.

3. Epidemiology
• Age: Incidence increases with increasing age and
peaks between 40-60 years
• Sex: Males > Females (7-15 times)
• Race: White Caucasians
• Geography: North European descent
• Genetics is Unclear (Autosomal dominant with
variable penetrance)

4. • Associated with:
1. Diabetes mellitus
2. Cigarette smoking
3. Alcoholism and liver disease
4. HIV infection
5. Epilepsy: Anti-epileptic drug Phenobarbitone
6. Trauma
7. Manual labor
8. Rheumatoid disease
9. Previous myocardial infarction
10.Plantar fasciitis
11.Peyronie disease

5. Patient Complaints
Fingers get in the way with:
Washing face
Combing hair
Putting hand in pocket
Racquet sports
Golf
Putting hand in glove

6. Symptoms
• First notice tender nodule or progressive
palmar cord development.
• May be painless, and may avoid care until
joint motion reduced.
• Symptoms may be present bilaterally, with
one hand occurring first (not necessarily
dominant hand).

7. • MCP joint affected first and then
PIP joint.
• Ring and small finger affected first,
after palmar involvement.

8. Palpable
Nodules and
Cords
• Firm nodules may be tender to palpation.
• Cords proximal to nodules painless.
• Atrophic grooves or pits in skin signify adherence to
the underlying fascia.
• Tender knuckle pads over dorsal aspect of PIP
joints--indicates aggressive disease.

9. Positive Table top Test:
The distance marked should be zero in
a normal hand with a negative table
top test.

10. Dynamic flexion contracture:
When MCP joint is at neutral, the PIP joint contracture
is more.
When MCP joint is flexed, the deformity at PIP is
reduced.
This is attributed to the Central Cord involvement.

11. Grading

12. • Grade I: Thickened nodule & band skin tethering
& puckering – full movements.
• Grade II: Pretendinous bands involved  extension
of fingers limited.
• Grade III: Flexion contracture.

13. Relevant
Anatomy

14. The Palmar Aponeurosis
• 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

15. Vertical Fibers
• Superficially they connect the aponeurosis to
the dermis
• Deep fibers are of three types:
1. Septa of Legueu and Juvara
2. McGrouther’s Fibers
3. Vertical septa between the lumbricals and flexor
tendons

16. • Septa of Legueu and Juvara are well developed fibrous
structures arising from the deep surface of the
aponeurosis at the level of the Metacarpal head and neck
• Pass down to the palmar plate and fascia over the
interossei
• Eight septa, one on either side - four fibro osseous tunnels
• Each tunnel has three compartments containing the
common neurovascular bundles and the lumbricals

17. Transverse Fibers
• Natatory Ligament (NL, Superficial transverse
metacarpal ligament, STML)
• Transverse ligament of the palmar aponeurosis
(TLPA): It is a distinct part of the palmar
aponeurosis and gives origin to the vertical fibers
of Legueu and Juvara.

18. Natatory & Central Cord

19. Pretendinous Bands
Three different insertions for the
pretendinous bands:
• Superficial layer: terminates into
the dermis distal to the MCP joint
• Intermediate layer: passes deep to
the natatory ligament and the
neurovascular bundles, merges
with the lateral digital sheath,
Spiral bands 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

20. Hypothenar Aponeurosis
• Covers the muscles of the hypothenar
eminence
• Continuous with the ulnar border of
the palmar aponeurosis
• Merges distally with the tendon of
Abductor Digiti Minimi and continues
close to the lateral digital sheath

21. Thenar Aponeurosis
• 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

22. Digital Fascia
• It holds the skin in
position as the fingers
or thumb move
1. Grayson’s ligament:
Midaxial, Palmar
2. Cleland’s ligament: Thicker,
Midaxial, Dorsal

23. 3. Lateral Digital Sheet: Superficial fascia
lateral to the Neurovascular bundles
4. Retrovascular band: Deep to the
Neurovascular bundles, longitudinal fibers

24. Spiral Band of Gosset:
Pretendinous band, the
lateral digital sheet and
the Grayson’s ligament
may involve the
retrovascular band
• Gradual contraction of the spiral cord pulls the
neurovascular bundle towards the midline which
may come to lie transverse to the long axis

25. Spiral Band of Gosset

26. Pathologic Anatomy
• Normal fascial structures in the hand and
digits are referred to as BANDS
• Diseased fascial structures in Dupuytren’s
are referred to as CORDS
• In Palm:
 Pretendinous cords are involved resulting in
MCP Joint flexion. Does not affect the
neurovascular bundles and are painless.
 Involvement of Vertical cords can cause pain
and triggering.

27. Basic Pathology
• Myofibroblasts are the histologic
hallmark of Dupuytren’s contracture
• Increase in:
–Type III collagen
–Total collagen
–Lysyl oxidase
–Glycosoaminoglycans
• Increase in cellularity (fibroblasts).

28. Pathogenesis
• Local ischemia at the microvascular
level  increase in fibroblast &
related cell types
• Fibroblasts then organize themselves
along line of stress  cords 
deformity

29. • Ischemia  free radicals 
increased cells (fibroblasts)
• Smoking, HIV, alcohol  promote
free radicals
• Increase Fibroblast 
Vasoconstriction  Ischemia (self
perpetuating cycle)

31. Role Of Protein Factors
• PDGF, FGF, TGF-B  increased
collagen production
• Myofibroblasts are more sensitive
Nodules & Cords:
Major forms of diseased tissues
Two distinct histological tissues

32. Nodules
• Dense cellular collections of myofibroblasts: indicates
centers of high metaplastic activity.
• LUCK described 3 stages of 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  Fascial hypertrophy
 Nodule cord units
3. Residual: Size reduces, Acelullar fibrous cords

33. Nodules, Pits, Skin Contractures

34. Cords
• No myofibroblasts
• Highly organised collagen structure similar
to tendon
• Nodules produce the contraction by
pulling the cords which expand across the
joints
Myofibroblasts found in dermal &
epidermal tissue cause recurrence

35. Treatment

36. Non Operative Management
• Collagenase injections show good results in
90% patients with a single injection and
maintained 9 months after treatment
• Radiotherapy, Dimethyl sulfoxide, Ultrasound,
Steroids, Colchicine, Alfa interferon: None has
shown any significant benefit

37. Operative Management
• Indications:
–A Positive Table Top Test: correlates with
MCP contracture of > 30-40°
–MCP joint contracture ≥ 40°
–Treatment of other digits on the same hand
should be considered when their MCP
contracture are 20-30° or more.
–PIP joint release if PIP joint contracture > 30°

38. • Important to distinguish true PIP joint
contracture from apparent contracture (due to
spiral cord)
• MCP joint contracture is measured with PIP
joint held in extension
• PIP joint contracture is measured with MCP
joint in flexion

39. Management Of Palmar Fascia
• Treatment options include:
–Radical vs. Selective vs. Segmental
Fasciectomy
–Fasciotomy
–Amputation
–Joint resection and arthrodesis

40. Surgical Fasciectomy
• Radical Fasciectomy: Mostly abandoned
– All palmar fascia removed
– High amounts of wound complications, and
recurrence
• Selective Fasciectomy: Most commonly used
– Removal of all diseased fascia in palm/finger
– Indicated when only ulnar one or two fingers
involved
– Rate of recurrence is 50%
– Need for another surgery: 15%
– Recurrence due to undetectable diseased fascia
remaining

41. • Segmental Fasciectomy
–Removal of one or more segments of
diseased fascia through multiple small
incisions in palms and fingers or
through transverse/longitudinal
plasties, with skin grafts

42. Incision (Basic Principles)
• No incision should cross a flexion crease at
right angles on wound closure

43. • Thin potentially avascular flap should be
avoided.
• Dissection start in normal anatomy and
proceed distally.
• Start cord release in palm and identify Neuro
Vascular Bundle>> then palmar-digital skin
>>then digital.

44. Skin Management
• 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 grafting

45. 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

46. Management of Volar Skin
• Three types:
–Direct closure
–Full-thickness skin grafting
–Open technique with wound
contraction

47. • Direct closure:
–Primary wound healing
–No need for skin grafts
–Simple post-op management
–Increased incidence of Hematoma and
Skin flap necrosis

49. • Full thickness skin grafting:
Pros:
• Less recurrence where full thickness graft used,
modulating effect on underlying fascia
Cons:
• Recurrence still possible beyond areas of graft
• Graft loss
• Hematoma formation
• Immobilization may cause stiffness
• Altered sensation on graft

51. • Open wound technique:
– Transverse incision in palm at level of midpalmar
crease and extensions in fingers
– Transverese incision is left open and covered with
non-adherent dressing
– Daily dry dressing changes, healing in weeks
– No granulation or epithelialization, instead
transverse wound contracts to pre-contracture
length
– Less hematoma, wound edge necrosis, and infection
– Inconvenience during 3-5 weeks for closure

52. Fasciotomy
• Diseased tissue incised but not removed
• Used mainly in elderly patients or severe
disease when unable to comply with
post-operative rehabilitation protocol

53. Joint Resection- Arthrodesis
• Severely contracted PIP joint
• Avoids the potential for recurrent
PIP joint contracture and potential
amputation neuroma

54. Amputation
• Rare
• May be indicated:
–In Flexion contracture of PIP joint, especially
little finger, when cannot be corrected
enough to make finger useful
–Or in case of vascular compromise

55. Newer Treatment
Modalities

56. Needle Aponeurotomy
• Fascia contractures sectioned
percutaneously with sharp-edged bevel
of local anesthetic needle.
• The treatment is only performed in
Europe, primarily France.
• Outpatient, $150 for 20 minute session
and requires no physical therapy.
• Temporary treatment, not cure.

57. Gamma Interferon
• Gamma-interferon is a cytokine
produced by t-helper lymphocytes.
• Shown to decrease fibroblast replication,
alpha-smooth-muscle actin expression,
and collagen production.
• Fails to have long term disease free effect

58. Complications
• Intra-operative:
– Digital nerve division.
– Hematoma formation.
– Wound healing difficulties (flaps).
– Vascular compromise of a digit.
• Post-operative:
– Patient compliance.
– Reflex sympathetic dystrophy (flare reaction).
(1-8% prevalence, 2x more common in women)
• Recurrence up to 63%.

59. Summary
• Dupuytren’s contracture is a genetic disease.
• Patients must understand that surgery is not a
cure, and has potential side effects.
• Future treatment more medical and less
surgical, with eventual cure to be at genomic
level.

60. Thank You