Percutaneous Fasciotomy in the management of Dupuytren"s contracture. Although PCF is associated with chances of recurrence but when done properly it gives excellent results with less number of complications.
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.
Student's elbow, or 'Olecranon Bursitis' is a condition where a small sack of tissue over the tip of your elbow becomes inflamed and swollen. The pointy bit of bone at the end of your elbow is called the 'olecranon' and the small sack which sits between the bone and the skin is called a 'bursa'.
Bhaskar Health News and Medical Education is leading source for trustworthy health, medical, science and technology news and information. Providing world health information Medical Education.
Bhaskar Health News and Medical Education is dedicated to medical students, physiotherapists, doctors, nurses, paramedics, physician associates, dentists, pharmacists, midwives and other healthcare professionals.
We're committed to being your source for expert health guidance. Bhaskar Health and Medical Education.
Source : https://www.bhaskarhealth.com
Health Shop: https://www.bhaskarhealth.org
@drrohitbhaskar @bhaskarhealth
#DrRohitBhaskar #BhaskarHealth
#Health #Medical #News #Physiotherapy
Percutaneous Fasciotomy in the management of Dupuytren"s contracture. Although PCF is associated with chances of recurrence but when done properly it gives excellent results with less number of complications.
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.
Student's elbow, or 'Olecranon Bursitis' is a condition where a small sack of tissue over the tip of your elbow becomes inflamed and swollen. The pointy bit of bone at the end of your elbow is called the 'olecranon' and the small sack which sits between the bone and the skin is called a 'bursa'.
Bhaskar Health News and Medical Education is leading source for trustworthy health, medical, science and technology news and information. Providing world health information Medical Education.
Bhaskar Health News and Medical Education is dedicated to medical students, physiotherapists, doctors, nurses, paramedics, physician associates, dentists, pharmacists, midwives and other healthcare professionals.
We're committed to being your source for expert health guidance. Bhaskar Health and Medical Education.
Source : https://www.bhaskarhealth.com
Health Shop: https://www.bhaskarhealth.org
@drrohitbhaskar @bhaskarhealth
#DrRohitBhaskar #BhaskarHealth
#Health #Medical #News #Physiotherapy
This PPT is mainly for the III yr MBBS - Students for whom this topic is important. Moreover mainly day today clinical practice practising doctors will come across these types of cases.
Hand Infections by Dr Rogers Ntambi.
This power point presentation is about infections of the hand, relevant anatomy, epidemiology, investigations and treatment options.
The deep palmar infections, webspace, space of parona and other hand infections have been included.
Some atypical hand infections have also been included
Plastic surgery and Orthopedics surgery approaches have also been shown.
Flexor tendons - enclosed by synovial sheaths.
Tendons - blood supply through synovial folds known as vincula, each
tendon having two, vincula longa and vincula brevia.
The sheath of the little finger is continuous with the ulnar bursa covering
the flexor tendons in the palm.
The flexor pollicis longus is covered by a single sheath throughout, the
radial bursa.
Synovial sheaths can be infected producing tenosynovitis. Infection can
spread throughout the sheath. Infection of the sheath of the little finger can thus spread up the distal aspect of the forearm into the space of Parona.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
3. Introduction
• In 1831,Baron Guillaume Dupuytren
described the condition of palmar
fascial contraction (Dupuytren’s disease).
• It 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.
4. • Other changes include:
–thinning of the overlying subcutaneous fat
–adhesion to skin
–and later pitting or dimpling of the skin.
5. History
• Felix plater (1536-1614) gave the 1st description
of palmar fibromatosis.
• Henry Cline (1750-1836) described the anatomy
& recommended surgical release.
• Astley cooper (1768-1841) explained the etiology
as repeated trauma and described percutaneous
fasciotomy.
• Guillaume Dupuytrene (1834) gave detailed
anatomic pathology, C/F, natural history, surgical
technique, postop care, response, follow up.
6. Epidemiology
• Age: Incidence increases with increasing age and
peaks between 40-60 years
• Sex: Males > Females (3-7 times)
• Race: White Caucasians
• Geography: North European descent
• Genetics is Unclear (Autosomal dominant with
variable penetrance)
• Family h/o +ve often
• Usually B/L. (Rt>Lt)
8. Dupuytren’s Diathesis
• Strong gene expression causing physical findings.
• Present earlier in life (20s and 30s).
• Aggressive cord development with high incidence
of multi-digit and bilateral hand involvement.
• A/w Knuckles pad (Garrod’s nodes), plantar
fibromatosis (Lederhose’s disease), penile fascial
involvement (Peyronie’s disease).
• High risk for poor surgical outcome due to higher
recurrence rates, greater risk of surgical technical
complications, and longer post-op care.
10. Chief Complaints
Patient complaints of fingers get in
the way with:
Washing face
Combing hair
Putting hand in pocket
Racquet sports
Playing Golf
Putting hand in glove
11. 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).
12. • MCP joint affected first and then
PIP joint.
• Ring > small finger affected first,
thereafter palmar involvement.
14. 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.
16. • First step – assess patient’s functional status,
complaints, goals.
• Careful documentation of degree of
contracture of each finger.
• Quality of overlying skin to plan intervention
and likelihood of leaving the wound open or
needing skin graft.
17. Hueston Positive Table top Test:
The distance marked should be zero in
a normal hand with a negative table
top test.
18. 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.
22. • The hand is divided into 5 rays.
• For each ray, the total contracture (MP+PIP+DIP) is
measured.
• Number system- depending on deformity
0–No lesion
N(0.5)–Palmar or digital nodule without flexion
deformity
1-Total flexion deformity between 0-45 degrees
2-Total flexion deformity between 45-90 degrees
3-Total flexion deformity between 90-135 degrees
4-Total flexion deformity >135 degrees
23. • For each ray, palmar lesions denoted as P and
for digital lesions D.
• For thumb P stands for lesions of the first web
space.
• H indicates fixed hyper-extension of DIP joint.
• R – recurrence after operation, E – extension
of disease not operated, A- finger amputation
26. 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
27. 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
28. • 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
29. 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
31. 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
32. 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
33. 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
34. 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
35. 3. Lateral Digital Sheet: Superficial fascia
lateral to the Neurovascular bundles
4. Retrovascular band: Deep to the
Neurovascular bundles, longitudinal fibers
36. 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
38. Pathologic Anatomy
• Normal fascial structures in the hand and
digits are referred to as BAND.
• Diseased fascial structures in Dupuytren’s
are referred to as CORD.
• 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.
39.
40. 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).
41. Pathogenesis
• Local ischemia at the microvascular
level increase in fibroblast &
related cell types
• Fibroblasts then organize themselves
along line of stress cords
deformity
44. 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
45. 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
47. 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
49. Non-Operative Management
• No finger contracture / no pain – Reassurance.
• Collagenase Studies show good results in 90%
patients with a single injection and maintained 9
months after treatment.
• Dimethyl sulfoxide, Ultrasound, Steroids,
Colchicine, Alfa interferon: None has shown any
significant benefit.
50. 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°
51. • 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
52. Management Of Palmar Fascia
• Treatment options include:
–Radical vs. Selective vs. Segmental
Fasciectomy
–Fasciotomy
–Amputation
–Joint resection and arthrodesis
53. 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
54. • 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
56. • 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.
57. 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
58. 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
59. Management of Volar Skin
• Three types:
–Direct closure
–Full-thickness skin grafting
–Open technique with wound
contraction
60. • Direct closure:
–Primary wound healing
–No need for skin grafts
–Simple post-op management
–Increased incidence of Hematoma and
Skin flap necrosis
61.
62. • 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
63.
64. • 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
65. Fasciotomy
• Diseased tissue incised but not removed.
• Used mainly in elderly patients or severe
disease when unable to comply with
post-operative rehabilitation protocol.
66. Joint Resection- Arthrodesis
• Severely contracted PIP joint.
• Avoids the potential for recurrent
PIP joint contracture and potential
amputation neuroma.
67. Amputation
• Rare.
• May be indicated:
–In Flexion contracture of PIP joint, especially
little finger, when cannot be corrected
enough to make finger useful.
–In case of vascular compromisation.
69. Collagenase
• Newly approved 1st line drug.
• Collagenase reconstitution according to
package insert.
• Currently FDA approved- costly.
• Injected straight into nodule.
• Minimally invasive.
• Manipulation of finger done after 24hrs
& before 7 days.
70. Needle Aponeurotomy
• Fascia contractures sectioned
percutaneously with sharp-edged bevel of
local anesthetic 25G needle.
• The treatment is performed in Europe
mainly, primarily France, now international
acceptence.
• Minimally invasive procedure.
• Day Care Procedure and requires no physical
therapy.
• High recurrence rate.
71. 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.
72. Postoperative Rehabilitation
• Commenced after early inflammatory phase (3-
5 days)
• ROM exercises for short periods, repetitive
• Splinting:
– Initially static for 2 weeks with MCP in 10-20°
Flexion, PIP straight and DIP joint free
– After 2 weeks PIP splint at night for 8-10 weeks
• Scar management
73. 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%.
74. In Case Of Intra Operative Arterial
Insufficiency
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
75. Recurrence
• Presence of diseased tissue in surgically treated
field.
• Cure at genome level: Surgical excision improves
hand function.
• Recurrence more common at young ages and in
Dupuytren’s diathesis.
• Most commonly diseased tissue from untreated
areas extends into treated areas.
76. • Recurrence rates are more in presence of
residual tissue incompletely excised,
leaving behind myofibroblasts in skin.
• Full skin grafts rarely recur, due to
complete removal of all nodular area in
dermis and epidermis.
77. OUTCOMES
• Outcome is variable according to severity of
disease, treatment type and joint affected.
• MCP joint contracture responds better than PIP
joint contracture for all type of treatment.
• Severe the disease, the more is risk of
complications.
• Release of contracted fingers does improve
function.
• No treatment changes the presence of disease
and recurrence/progression is expected.
78. FUTURE DIRECTIONS
• Focused on prevention of contracture.
• Radiation is being investigated for prevention of
disease progression.
• Success rate is 69%.
• No major long-term side effects.
79. Summary
• Dupuytren’s contracture is a genetic disease.
• Patient should counsel for that the disease is part
of their genetic makeup and surgeon can only treat
the symptoms and recurrence is expected.
• Newer treatment more medical and less surgical,
with eventual cure to be at genomic level.