DUPUYTREN'S DISEASE - DNB Orthopaedics MS Orthopedics MRCS Exam GUIDE - Orthodnb.com

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Monday, 18 June 2018

DUPUYTREN'S DISEASE

DUPUYTREN'S DISEASE
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  • 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
  1. Partial (selective) fasciectomy
  • indicated only when ulnar one or two fingers alone involved
  • less post surgical morbidity
  • only mature deforming tissue excised
  1. Complete fasciectomy
  • associated with hematoma, joint stiffness, delayed healing
  • do not prevent recurrence of the disease
  1. 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
  1. Amputation
  • rarely indicated – flexion contracture of PIP of little finger – severe and can not be corrected
  1. 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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