2. History
• Baron Guillaume Dupuytren
▫ Described it in a lecture in 1831
• Felix Plater 1st described it in 1614
• Henry Cline
▫ described pathological anatomy and features of
this disease
3. Dupuytren’s disease
• Progressive, overarching, superficial
fibromatoses
▫ (peyronie’s disease, ledderhose’s disease)
• Nodular thickening & contracture
• Palmar and digital fascia
• MCP & PIP joint level
4. Epidemiology
• Most prevalent in Northern Europe
• Historically, Nordic, Caucasian, Anglo-Saxon &
Viking disease
• Male:female is 6:1
• Male in 50s, women in 60s
• Genetic disorder, Autosomal dominant
inheritance
6. Palmar fascia
• Firm, flexible framework covering soft tissue
• Tethering skin to underlying structures
• 2 layers
▫ Deep fascia
▫ Superficial fascia/palmar apponeurosis
• Palmar apponeurosis
▫ triangular fascia with apex in continuity with
palmaris longus
7.
8. Pretendinous bands
Natatory ligament
Proximal transverse palmar
ligament
Proximal commissural ligament
Distal commissural
ligament of 1st
webspace(lig of grapow)
Palmar cutan.br of median nerve
Palmaris longus tendon
Triangular space
9. Palmar apponuerosis
• 3 types of fibres
▫ Longitudinal,transverse,vertical
• Longitudinal:
▫ From PL to distal palmar crease,attachments to retrovascular fascial
structures,deep dermis, distally bifurcating into slips attaching on sides of MCP
joint
• Transverse:
▫ Proximal transverse band,at level of distal palmar crease, deep to longitudinal
pretendinous band,radially prox.commissural ligament
No affected by DD
▫ Distal transverse band(natatory ligament),ulnarly splitting & enclosing NVB &
ADM, radially distal commissural ligament of 1st web space(lig of GRAPOW)
Affected by DD
• Vertical(fibres of Legueu and juvara)
▫ Attaching deep dermal surface to deep palmar fascia
▫ Series of 8 Vertical septa, splitting longitudinal compartments
10.
11.
12. Digital fascia
• Complex palmar-digital fascia junction
• Deep & intermediate fibres bifurcate
▫ Contribute to digital retrovascular bands
• Invested by dorsal and volar fascial sheets
▫ Superfiscial to ext. & flex. mechanisms
• Lateral structures investing NVB
▫ Cleland’s ligament
V shaped dorsal fibre bundles from prox & distal of PIPJ to lateral
digit.sheets (not involved in disease)
▫ Grayson’s ligament
From flex.tendon sheath to skin volar to NVB
▫ Transverse retinacular ligament
From volar capsule of PIPJ dorsally into extensor mechanism
• Spiral bands from pretendinous bands; to lateral digital
sheets
13. Digital fascia Grayson’s ligament
Natatory ligament
Pretendinous band
Transverse fibers of
palmar aponeurosis
Spiral band
Lateral digital sheet
Cleland’s ligament
14. 1st web space
• Longitudinal fibres
▫ Extend radially, insert into skin at MCPJ level
▫ Insert into I/M septum between adductor pollices
& 1st D/I muscle
▫ Into flexor tendon sheath of index finger
• Transverse fibres
▫ Natatory ligament continues as ligament of
Grapow
▫ Proximal transverse fibres as proximal
commissural ligament
15.
16. Basic science
• Fibro-proliferative disease
• Alterations in:
▫ β-catenin pathway
▫ Fibroblast gene expression
▫ Extracellular matrix genes down-regulation
▫ Deposition of collagen type 1 & 3, extracellular
matrix
▫ Myofibroblast hyperactivity
▫ Role of androgenic hormonal receptor
17. pathology
• 3 phases
• Proliferative phase
▫ Nodule formation in palmar fascia
▫ Increased fibrinolytic activity and myofibroblast
formation
• Involutional phase
▫ Increased nodular thickening
▫ Joint contracture formation
▫ Type 3 collagen deposition
• Residual phase
▫ Type 3 replaced by type 1 collagen
▫ Myofibroblasts disappear
18. Disease process
• Mild thickening to severe contractures
• Diseased bands named as cords
▫ Palmar,digital,palmodigital,hypothenar and 1st
web space cords
19. diseased
structure
Anatomic origin Clinical
significance
Palmar cords Pretendinous
cord
Pretendinous band MCP joint flexion
contracture
Vertical cord Vertical fibers of
McGrouther or septa
of Legueu and Juvara
Causes painful
triggering
Palmodigital
cords
Spiral cord Pretendinous band,
spiral band, lateral
digital sheet,
Grayson’s ligament
Displaces the
Neurovascular bundle
medially and
superficially (spiral
nerve)
Natatory cord Natatory ligament
(distal fibers)
Webspace adduction
contracture
20. diseased
structure
Anatomic origin Clinical significance
Digital cords Central cord Pretendinous cord
(digital extension)
PIP joint flexion
contracture
Retrovascular
cord
Retrovascular band of
thomine
PIP and DIP joint
flexion contracture;
prevents full correction of PIP joint
contracture
Lateral cord Lateral digital sheet
(often closely
associated with
pretendinous and
natatory cord)
PIP and DIP joint
flexion contracture;
Displaces neurovascular bundle
medially
Abductor digiti
minimi cord
Abductor digiti minimi tendon PIP joint flexion
contracture
Thumb and first
webspace cords
Proximal
commissural
cord
Proximal commissural
ligament
First-web adduction
contracture
Distal
commissural
cord
Distal commissural
ligament
First-web adduction
contracture
Thumb
pretendinous
cord
Pretendinous band MCP joint flexion
contracture
21.
22. Grading
• Grade 1
▫ Thickened nodule and band in the palmar
apponeurosis; may have associated skin
abnormalities
• Grade 2
▫ Development of pretendinous and digital cords
with limitation of finger extension
• Grade 3
▫ Presence of flexion contracture
27. Management plan
• Thorough history
▫ impairment in hand shaking, fitting of gloves,difficulty
placing the affected hand in a pocket, and impairment in
grasping large objects.
• Physical examination
▫ Functional limitations
▫ Degree of contracture of each finger
▫ Quality of overlying skin
▫ Hand examination
compressive neuropathies
▫ Other fibromatosis in body
• Initial consultation
▫ About disease origin,course,syptomatic treatment,disease
recurrence & progression
29. No contracture,no pain
• Only skin pitting,hand mass(patient ‘ll say) or
tightness in fingers or palm
• Explain,reassure and instructions when to
return for intervention
33. Needle apponeurotomy
• Percutaneous needling into cord followed by
manipulation
▫ 25 G needles
• Cord weakening
• Cord rupturing by finger manipulation
• Digital nerve neuropraxia
• Skin tear
• High recurrence
• Disease not removed
• Less invasive,no incision
• Effective for MCPJ cords
34.
35. collagenases
• Collagenase enzyme(clostridium histolyticum)
▫ Xiaflex at a dose of 0.58 mg per injection
• CRUCIAL: patient counselling for swelling & bruising(indicates effect of
enzyme)
• hand prep, 3 sites injection within cord
• Return for manipulation and cord release
▫ 24 hours or 1 week later
▫ Under LA
• Splinting of hand at night for 3 months
• Effective for MCPJ
• Minimally invasive
• Low recurrence rate
• Swelling,bruising,skin tear
• Deep injection ruptures FLEXOR TENDONS
• Two visits,one cord at a time
• costly
37. Limited fasciectomy
• Standard
▫ surgical excision of diseased tissue/Cords
• The more the excision ,the lower the recurrence
• Strict post-operative care
▫ splinting till suture removal then night splining
• Complications of surgery:
▫ Infection,delayed wound healing,nerve injury,post
surgical scar contractures
• Incision
▫ Brunners-type incision
▫ Straight line over cord with multiple Z-plasties
38.
39.
40. Dermatofasciectomy/skin grafting
• For extensive/recurrent/sin involving disease
• All scarred fascia &overlying skin removed
• Resurfaced with skin graft
• Potential risk of graft loss
• Long rehabilitation
41.
42. Soft tissue distraction
• E.g digit widget, a skeletally anchored hardware
▫ Under local block
• Stretches soft tissues
▫ Collateral ligaments,NVB
• Straightens the contracture
▫ Usually in 5 weeks
• 2nd stage removal of dupuytren’s disease
▫ Limited or dertmatofasciectomies
• Postoperative rehabilitation
• Effective fore severe PIPJ contractures
• Two stages, tolerate the device for several weeks
43.
44. delimmas
• Pale finger
▫ Ait 20 minutes,warm saline,vasodilators,injury
assesment
• PIPJ intrinsic flexion
▫ Controversial to release joint
▫ Releasing checkrein and accessory collateral
ligament
• Simultaneous release of dupuytren’s contracture
and carpel tunnel syndrome
▫ Risk of Post–op pain(unproven)
45. Other techniques
• Skeletal traction
• Wedge osteotomy
▫ Dorsal wedge of proximal phalanx
• Total volar tenoarthrolysis
▫ Sectioning volar plate and flexors(FDS,FDP)
• PIP arthrodesis
• Amputation
