DUPUYTREN'S DISEASE

• proliferative fibroplasia of the s/c palmar tissue occurring in the form of nodules and cords – result in secondary progressive irreversible flexion contractures of finger joints
• other 2⁰ changes include thinning of overlying s/c fat, adhesion to skin, pitting/dimpling of skin
• ectopic deposits of Dupuytren's diseases occur at various areas
  • medial plantar fascia – Ledderhose disease – 5%
  • plastic induration of penis – Peyronie disease – 3%
  • knuckle pads of dorsum of PIP
  • Dupuytren's disease + these associated findings = Dupuytren diathesis – progressive and recurrent disease

Etiology

• cause unknown
• trauma to hand – type of labor – heredity – vascular insufficiency – cigarette smoking

Pathogenesis

• nodules and cords – by fibroplasia and hypertrophy of existing fibers of palmar fascia
• nodules formed first – pass through proliferative stage – involutional stage – residual stage – intermittent stress – cords formed from nodules – contracture

Clinical features

• more in men – 10 times
• Scandinavian and Celtic origin
• more in epilepsy, DM – alcoholism
• b/l involvement
• starts in line with ring finger at distal palmar crease – progress to little finger – ring and little finger more affected than rest
• flexion contractures of MCP and PIP
• rarely pain or itching

Treatment

• no treatment in absence of any contractures – nodules and cords painless
• slowly progressing , non disabling contractures – examined every 3 months
• operated when disease is mature – when surgical trauma has less chance to accelerate the disease
• surgical intervention at proliferative stage – stiffening and increase in contractures
• Hueston's table top test – patient no longer able to place hand flat over table top – consider surgery- ie. MCP contracture >30⁰
• other considerations are
  • disability of joint contracture
  • degenerative joint disease
  • predisposing factors to poor outcome
• clostridial collagenase injections – intralesional triamcinolone acetonide – non operative lesions

Surgical procedures

1. Subcutaneous fasciotomy

• least extensive
• in elderly who are not concerned with the appearance of disease or in poor general health patients

2. Partial (selective) fasciectomy

• indicated only when ulnar one or two fingers alone involved
• less post surgical morbidity
• only mature deforming tissue excised

3. Complete fasciectomy

• associated with hematoma, joint stiffness, delayed healing
• do not prevent recurrence of the disease

4. Fasciectomy and skin grafting

• in young with poor prognosis d/t epilepsy, alcoholism etc
• skin, underlying fascia excised
• full or split thickness skin graft applied
• prevents recurrence

5. Amputation

• rarely indicated – flexion contracture of PIP of little finger – severe and can not be corrected

6. Joint resection and arthrodesis

• alternative for severely contracted PIP

Complications

• digital nerve injury
• infection
• recurrence – family h/o, early age of surgery, surgery in women more chance of recurrence
• tender scar
• c/c edema
• reflex sympathetic dystrophy
• limited range of motion
• hematoma – devastating complication

Prognosis

• family h/o ,alcoholism, smoking– bad prognosis
• females – late appearance – slow progression – long term results after surgery worse than men
• DM – those on insulin more chance than on OHA
• faster progression if ulnar side
• faster progression, recurrence if b/l involving knuckle pad and nodules in plantar fascia

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