This document provides information on Dupuytren's contracture including its history, epidemiology, clinical presentation, anatomy of the palmar fascia, pathogenesis, clinical evaluation, management options, postoperative care, and complications. It describes Dupuytren's contracture as a benign fibromatosis of the palmar and digital fascia. Key points include that it typically presents as nodules and cords in the palm that can cause finger contractures, affects mostly men over 40 of Northern European descent, and can be managed with fasciectomy or collagenase injections to release contractures.

2.  Baron Guillaume Dupuytren, 1831
› Described the condition of palmar fascial
contraction
› It is benign fibromatosis of palmer and digital
fascia.

3.  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 study
2. Smoking
3. Manual work
4. Diabetes
5. Epilepsy

4.  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

5.  History and examination
 Palpable nodules , cords, positive table top test
and contracture
 Dynamic contracture- goniometer

8.  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
8

13.  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

14.  Exist throughout
 Superficially they connect the PA to the dermis
 Deep fibers are three types
1. Septa of Legueu and Juvara
2. McGrouther’s Fibers
3. Vertical septa between the lumbricals and
flexor tendons

15.  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

16.  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

17.  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

18.  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

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

21.  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

23.  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

24.  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

25. 3. Lateral Digital Sheet – superficial fascia
lateral to the nv bundles – NL , Spiral band
4. Retrovascular band – deep to the nv bundles
longitudinal fibers

26.  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

29. 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

32.  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

33. Anatomical
Distribution
Skin Involvement
Contracture
Digital Allen’s Test
Maturity
General Condition

34. Normally Ulnar
One or more digit
Different stages of
involvement

37. Nodules, Cords, Pits, Skin
Shortening

38.  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

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

41.  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

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

43.  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.

44.  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

45.  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

48.  Fasciotomy
 Fasciotomy and grafting Extensive
Dupuytren’s --- Firebreak
 Fasciectomy
1. Segmental
2. Complete Longitudinal fasciectomy
3. Radical Palmar Fasciectomy
4. Dermofasciectomy

49.  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

58.  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

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

61.  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.

62. 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

63.  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

64.  17-19 % 0verall
 Intra operative
Nerve Injury
Digital circulation
Skin flap Thinning , Button hole
 Post operative
Haematoma
Skin loss
Infection
Edema
Wound Dehiscence

65.  Dupuytren’s Flare – Inflammatory reaction occurring 2-3
wks after the surgery
More common in women 20 %
Acute carpal tunnel syndrome
Redness, pain, edema, stiffness
Sympathetic blockade, oral steroids, carbamazapine
 Reflex Sympathetic Dystrophy – 5 x more common in
women (5 %)
Pain, edema, stiffness, vasomotor symptoms
Sympathetic blockade, oral steroids, carbamazapine

66.  Recurrence is the reappearance of disease in the
area of previous surgery
26-80 %
 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 tissues
2. Failure to correct PIP joint contractures at initial
surgery

68.  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

69.  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.”)