· deforming fibrotic condition of the palmar aponeurosis
· incidence is 4-6% (in Caucasians)
· more common in elderly males
· M:F = 2:1 to 10:1 (greater sex difference in younger patients)
· in 17% of males > 65 yrs
· bilateral in 50%
· virtually confined to Caucasians
· significant racial differences
· most common in Scandinavia and British Isles (Celtic)
· rare in Mediterranean
· almost unseen in blacks and Asians
· there is a hereditary component
· probably autosomal dominant with incomplete penetrance
· may be Dupuytren’s diathesis with similar cellular changes in
· hands (palmar and digital fibromatosis)
· dorsal knuckle pads
· feet (plantar fibromatosis - Lederhose’s disease)
· penis (Peyronie’s disease)
· increased incidence in alcoholism
· 30% higher prevalence in diabetics
· Dupuytren’s seen in 40% of institutionalised male epileptics
· may be related to phenobarbitone administration
· association suggested in past
· weight of evidence against it
· not more common in manual workers
· not related to handedness
· not seen in dark-skinned races who use hands
· increased incidence
· may cause microvascular occlusion
· increased incidence found after Colles fracture
· specific regional injury may accelerate appearance
· active contractile cell
· causes fascial contraction
· origin is perivascular fibroblast
· conversion to myofibroblast may be triggered by localised hypoxia in response to microvascular occulsion
· presence of type III collagen in diseased fascia
· all type I in normal fascia
· type III found in scar tissue
· role controversial
· may be response to injury
· initiating event is microvascular ischaemia
· leads to conversion of
· ATP to hypoxanthine
· endothelial xanthine hydrogenase to xanthine oxidase
· xanthine oxidase converts hypoxanthine to uric acid
· releases free radicals
· free radicals stimulate fibroblast proilferation
Palmar aponeurosis
· almost always involved
Anatomy
· starts proximally
· continuous with palmaris longus if present
· fans out to pretendinous bands to each digit
· bands
· attach to palmar skin just beyond MCP jt (accounts for DPC)
· bifurcate at level of MCP jt and enter finger deep to NV bundle
Nodule
· nodule is pathognomonic of Dupuytren’s
· most frequently appears in palm near DPC
· in pretendinous band of ring and little fingers
Cord
· pretendinous bands become cords
· bands are normal tissue
· cords are diseased tissue
· nodule in band induces formation of cord proximal and distal
· cause MCP contracture
· do not alter anatomy of NV bundles
· can be excised safely proximal to DPC
Superficial transverse metacarpal ligament
· syn. superficial transverse palmar ligament
· lies deep to palmar aponeurosis
· passes across MCP joints
· not involved in disease process (?except in thumb)
Natatory ligament
Anatomy
· passes across palm at level of web spaces
· gives structure to web
· attaches to each fibrous flexor sheath
· contributes to lateral digital fascia
· on ulnar side
· blends with hypothenar fascia at base of little finger
· on radial side
· continues to thumb web
· terminates in skin at PIP jt of thumb
Pathology
· commonly involved
· causes contracture of
· web space
· finger joint
· narrows web from U to V
· results in inability to separate fingers
· contributes to PIP jt contracture
· by contribution to lateral digital fascia
· contributes to thumb web contracture
Hypothenar fascia
· condensation of fascia along ulnar border of palm
· may become involved
Anatomy
· fascia comes from
· pretendinous bands
· superficial transverse metacarpal ligament
· natatory ligament
Pathology
· pretendinous bands of thumb and index finger rarely involved
· thumb web contracture may occur from contracture of
· superficial transverse metacarpal ligament (?)
· natatory ligament
· starts with nodule at proximal crease of thumb
· may develop into cord in web space
Anatomy
· pretendinous bands
· bifurcate at MCP jt
· pass deep to NV bundle
· lie on each side of finger
· called spiral bands
· natatory ligament
· sends fibres down each side of finger
· pass superficial to NV bundle
Pathology
· spiral bands become spiral cords
Anatomy
· volar fascia consists of
· superficial fascia like tube around finger
· condensations deep in finger
· superficial fascia
· forms lateral condensation called lateral digital sheet
· is fibrofatty on volar surface
· deep fascia consists of
· Grayson’s ligament
· Cleland’s ligament
· both pass from tendon sheath to lateral digital sheath
· Grayson’s ligament is
· volar
· superficial to NV bundle
· Cleland’s ligament is
· midlateral
· deep to NV bundle
Cords
· four cords contract PIP jt
1. central cord
· direct extension of pretendinous cord
· arises from superficial fascia of volar surface of finger
· passes distally between NV bundles
· adherent to skin
· attaches to flexor sheath and bone of P2
· fibres of Grayson’s ligament become part of cord at attachment
· common cause of PIP jt contracture
· found in little and ring fingers
2. spiral cord
· continuation of pretendinous cord
· passes deep to NV bundle distal to MCP jt
· joins lateral digital sheet
· becomes continuous with Grayson’s ligament
· fibres then pass superficial to NV bundle
· attach to flexor sheath at P2
· fibres therefore spiral around NV bundle
3. lateral cord
· disease of lateral digital sheet
· may extend distally
· may cause DIP jt contracture
4. retrovascular cord
· diseased fascia deep (dorsal) to NV bundle
· separate to Cleland’s ligament (not involved)
Displacement of NV bundle
· normal parts of fascia that produce spiral cord are
· pretendinous band
· spiral band
· lateral digital sheath
· Grayson’s ligament
· as this spiral structure contracts it straightens
· causes NV bundle to spiral around it
· as PIP jt contracts, spiral cord lies more volar
· NV bundle becomes subcutaneous
· danger zone is between
· distal palmar crease
· proximal crease of finger
· should divide pretendinous cord to allow finger to be extended
Flexion deformities
· MCP jt flexion always correctable
· collateral ligaments tightest in flexion
· flexion deformity does not lead to collateral shortening
· resection of central cord restores extension
· PIP jt flexion not always correctable
· collateral ligaments tightest in extension
· flexion deformity leads to collateral shortening
· contracture of volar plate and flexor sheath may contribute to fixed deformity
· may present with thickening in palm
· usually complain of problems related to flexion defomities of fingers
Nodule
· starts with nodular thickening in ulnar palm
· along line of little or ring finger
· just proximal to distal palmar crease
· skin becomes dimpled and adherent (pitting)
Band
· extends distally to involve little or ring finger
· if extend to fingers cause
· flexion deformities of MCP jts and PIP jts
· lack of finger abduction
· PIP flexion may lead to secondary DIP hyperextension
Severity
· table-top test of Hueston
· positive when hand cannot be placed fully flat on table
· indicates deformity severe enough to warrant surgical intervention
· PIP flexion deformity
· assess PIP extension with MCP jt extended maximally
· then maximally flex MCP jt to eliminate ‘tenodesis’ effect of central cord
· allows assessment of intrinsic PIP jt contracture
Dorsum
· may be thickening of dorsal knuckle pads (Garrod’s pads)
· Lederhose’s disease
· plantar fibromatosis
· Peyronie’s disease
· fibrosis of corpus cavernosum
Indications
· absence of digital flexion deformity
· negative table-top test
Methods
Observation
· spontaneous regression may occasionally occur
Drugs
· allopurinol, trypsin and steroid have been tried
· no consistent results
Traction
· continuous passive skeletal traction
· feeling of release after 4-5 days
· near full extension achieved at 2 weeks
· used preoperatively to make surgery easier
Indications
· digital flexion deformity
· positive table-top test
· contracture in thumb web space
· premature surgery may hasten progress of disease
· equivalent to injury of hand
Fasciotomy
· limited palmar subcutaneous fasciotomy
· should never be performed distal to DPC
· temporising solution
· indicated for
· elderly patients
· patients unsuitable for anaesthesia
· facilitation of access to more definitive procedures
Total fasciectomy
· total palmar fasciectomy
· done in hope of eliminating possibility of recurrence
· should not be performed because of significant postoperative morbidity
Partial fasciectomy
· confined to rays involved
· current procedure of choice
Dermatofasciectomy
· excision of fascia and overlying dermis
· defect covered by full-thickness graft
· from medial arm or antecubital fossa
· role controversial
· may eliminate recurrence
· may be indicated when local recurrence expected
· usually reserved for digits
Amputation
· indicated in
· elderly patient
· severe PIP deformity unlikely to be correctable
Principles
· dissection of digital nerves
Equipment
· loupes or operating microscope
· tourniquet and Esmarch bandage
Incision
Longitudinal
· linear midpalmar and middigital incision
· most commonly used
· crossing flexion creases at right angles
· DPC, base of finger and crease of PIP jt
· can be multiple
· closure with three z-plasties
· so that horizontal limbs fall over flexion creases
Transverse
· of McCash
· for severe involvement
· proximal and parallel to DPC
· separate middigital incisions for fingers
· leaves gap of 3-4 cm after correction
· heals spontaneously in 4-6 weeks
· advantages are
· allows early mobilisation
· avoids haematoma, pain and oedema
Fasciectomy
· skin flaps elevated from diseased fascia
· as much subcutaneous tissue left on flaps
· pretendinous cord divided just distal to superficial palmar arch
· NV bundle safe as deep to palmar fascia
· NV bundle exposed and dissected out
· followed carefully distally to distal phalanx
· may be superficial to fascia distal to DPC
· diseased tissue removed
PIP jt contracture
· can usually correct 50% of flexion deformity by excision of diseased tissue
· should perform further procedures if flexion > 90o
· may address residual contracture by following procedures
· closed manipulation
· open flexor sheath distal to A2 pulley
· release volar plate
· release collateral ligaments
· better to accept mild residual deformity than cause postoperative scarring
Closure
· release tourniquet
· obtain haemostasis
· insert small drain
· close skin
· z-plasties as above
· bulky dressing with fingers in extension
· may use plaster slab
Postoperative
· hand elevated
· drain removed at 24-48 hrs without disturbing dressing
· if severe pain, inspect wound for haematoma
· sutures removed in 10 days
· active flexion started
· extension splint worn for 3 weeks
· for severe deformity, night splint for further 12 weeks
Complications
· reflex sympathetic dystrophy
· more common in women
· presposed to by postoperative pain, haematoma and oedema
· division of digital nerves and arteries
· repair at time of surgery
· stiff PIP jt
· with subsequent loss of grip strength
· with overzealous PIP correction
General
· young age
· female
· positive family history
· epileptic / diabetic
· Dupuytren’s diathesis
Local
· rapidity of appearance and progress of nodules
· surgery not curative
· further disease may be
· recurrence (new disease in area that has been operated on previously)
· extension (disease in area that has not been operated on)
· incidence depends on
· age of patient
· severity of preoperative disease
· duration of followup
· incidence is 50%
· requirement for repeat surgery is 15%
· most common in 1st few postoperative months
· may occur after many years