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Dupuytren’s Contracture

 


- See: Surgical Treatment of Dupuytren's:

- Discussion:
    - originally described by Baron Guillaume Dupuytren in 1831;
             - ref: Guillaume Dupuytren: His Life and Surgical Contributions
    - usually appears between age 40 to 60 years;
    - disease occurs more often and is more severe in males or persons of Northern European Origin;
    - may be associated w/ alcoholism, epilepsy (due to medications), and/or diabetes, and has autosomal dominance in some cases;
    - patho-anatomy
            - extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) in Dupuytren disease.
            - Dupuytren's contracture. An electron microscopic, biochemical, and clinical correlative study.
            - The expression of platelet derived growth factor gene in Dupuytren's contracture. RM Terek et al.  JBJS. Vol 77-A. 1995. p 1-9.
  - etiology:
            - associated w/ myofibroblast proliferation & increases in type III collagen and platelet derived growth factor B;
            - immature type 3 collagen is proportionately increased in relation to normally occurring type I collagen within affected palmar fascia;
            - contractile potential of myofibroblasts causes contraction of the collagenous palmar fascia and overlying skin and fingers;
    - prognosis:
            - a more aggressive disease is one that is associated w/:
                    - positive family history;
                    - onset before age 40;
                    - bilateral involvement;
                    - involvement of radial digits;
                    - ectopic disease (feet, penis);

- Clinical Findings:
     - patients may present with a fixed flexion deformities in the MP, PIP, and rarely the DIP joints;
     - occurs most often in the ring and little fingers, and is bilateral in 45%;
     - patho-anatomy
     - vascular:
            - a digital Allen's test may reveal sluggish filling on either side of the affected digit;
     - palm:
            - fibrous nodules appear over pretendinous bands;
            - involvement often begins w/ thickening of pre-tendinous cord over 4th ray;
     - MP joint:
            - mp contracture may be caused by pretendinous cord contracture or by contracture of spiral band;
            - 20 to 30 deg flexion contracture is indication for surgery;
            - abduction may be limited as natatory ligament becomes contracted;
     - PIP joint:
            - central cord is in continuity with pretendinous cord;
            - spiral cord can manifest as an extension of pretendinous cord thru spiral band or at musculotendinous junction of intrinsics;
            - any degree of flexion contracture of pip is indication for surgery;
            - consider whether there is an associated trigger finger;
     - thumb:
            - may show a flexion deformity along w/ a web space contracture;
     - ectopic disease:
            -
Ledderhose Disease
                  - associated fibrosis in feet (5% of patients);
            - Peyronie's disease:
                  - associated fibrosis in penis and knuckle pads (3% of patients);
                  - these pts generally have a higher rate of recurrence;
            - Dorsum of PIP: (knuckle pads);

- Non-Surgical Treatment:
    - Dupuytren's nodules can be injected on a 6 week serial basis w/ 1-3 cc of triamcinolone (40 mg/ml);
          - patients may note a softening and flattening of the nodules over months;
    - clostridial collagenase:
          - injections of 10,000 units into the area of maximal involvement may dissolve the Dupuytren cords;
          - technique is most appropriate for disease limited to the palm and MP joints;
          - results may be seen with in weeks;
          - references:
                - Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture
                - Collagen as a clinical target: nonoperative treatment of Dupuytren's disease
                - Partial Improvement of Dupuytren Contracture Following a Wasp Sting

Surgical Treatment of Dupuytren's  
-
choice of incisions


- References:

The early history of contracture of the palmar fascia. Part 1: The origin of the disease: the curse of the MacCrimmons: the hand of benediction: Cline's contracture.

The early history of contracture of the palmar fascia. Part 2: The revolution in Paris: Guillaume Dupuytren: Dupuytren's disease.

Abductor digiti minimi involvement in dupuytren’s contracture of the small finger.

Percutaneous Fasciotomy for Dupuytren's Contracture