dupuytrens disease
DESCRIPTION
dupuytrens contractureTRANSCRIPT
Baron Guillaume Dupuytren, 1831› Described the condition of palmar fascial
contraction› It is benign fibromatosis of palmer and
digital fascia.
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 study2. Smoking3. Manual work4. Diabetes5. Epilepsy
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
History and examination Palpable nodules , cords, positive table
top test and contracture Dynamic contracture- goniometer
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
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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
Exist throughout Superficially they connect the PA to
the dermis Deep fibers are three types1. Septa of Legueu and Juvara2. McGrouther’s Fibers3. Vertical septa between the lumbricals
and flexor tendons
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
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
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
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
Deep layer – passes vertically down at the level of the A1 pulley and terminates in the vicinity of the extensor tendon
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
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
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
3. Lateral Digital Sheet – superficial fascia lateral to the nv bundles – NL , Spiral band
4. Retrovascular band – deep to the nv bundles longitudinal fibers
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
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
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
Anatomical Distribution
Skin Involvement
Contracture
Digital Allen’s Test
Maturity
General Condition
Normally Ulnar
One or more digit
Different stages of involvement
Nodules, Cords, Pits, Skin Shortening
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
Age General Health Motivation Type of hand – Aesthetic , Workman’s H/O CRPS Type of involvement Deformity and progression
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
Indications – mp contracture > 30* positive table top test pip contracture > 20* recurrence ..> 20 %Manage skin – fascia (band) – joint
contracture
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.
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
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
Fasciotomy Fasciotomy and grafting Extensive
Dupuytren’s --- Firebreak Fasciectomy 1. Segmental2. Complete Longitudinal fasciectomy3. Radical Palmar Fasciectomy4. Dermofasciectomy
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
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
Technique of check rein release. 1, Volar plate. 2, Check rein ligament. 3, Collateral artery. 4, Transverse arterial branch.
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.
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
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
17-19 % 0verall Intra operative
Nerve Injury Digital circulationSkin flap Thinning , Button hole
Post operative Haematoma Skin lossInfection Edema Wound Dehiscence
Dupuytren’s Flare – Inflammatory reaction occurring 2-3 wks after the surgeryMore common in women 20 % Acute carpal tunnel syndrome Redness, pain, edema, stiffnessSympathetic blockade, oral steroids, carbamazapine
Reflex Sympathetic Dystrophy – 5 x more common in women (5 %)Pain, edema, stiffness, vasomotor symptomsSympathetic blockade, oral steroids, carbamazapine
Recurrence is the reappearance of disease in the area of previous surgery26-80 %
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 tissues2. Failure to correct PIP joint contractures at
initial surgery
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
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.”)