2. Dupuytren’s Disease Baron Guillaume Dupuytren, 1831
Described the condition of palmar fascial contraction

3. Epidemiology 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
Alcohol and liver disease Icelandic cohort study
Smoking
Manual work
Diabetes
Epilepsy

4. Strong Diathesis Strong family history Young patient
Bilateral disease with radial involvement
Diffuse dermal involvement
Lederhosen – soles of feet
Peyronie’ s disease – penile
Garrod’s knuckle pads – PIP joints
Recurrence and extension

5. Palmar Fascia Anatomy Palmar Aponeurosis Hypothenar Aponeurosis
Digital Fascia

6. The Palmar Aponeurosis
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

7. Pretendinous Bands
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

8. Deep layer – passes vertically on either side FTS at the level of the A1 pulley and terminates in the vicinity of the extensor tendon

9. Pretendinous Bands

10. Palmar Aponeurosis - Vertical Fibers
Exist throughout
Superficially they connect the PA to the dermis
Deep fibers are three types
Septa of Legueu and Juvara
McGrouther’s Fibers
Vertical septa between the lumbricals and flexor tendons

11. 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

12. 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

13. Palmar Aponeurosis – Transverse Fibers
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

14. Hypothenar Aponeurosis
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

15. Thenar Aponeurosis
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

16. Digital Fascia
The digital fascia holds the skin in position as the fingers or thumbs are moved
Grayson’s ligament – midaxial, palmar
Cleland’s ligament – thicker, midaxial, dorsal

17. Digital Fascia
3. Lateral Digital Sheet – superficial fascia lateral to the nv bundles – NL , Spiral band 4. Retrovascular band – deep to the nv bundles longitudinal fibers

18. Pathologic Anatomy
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

20. Central cord ADM

21. Natatory & Central Cord

22. 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

23. Spiral Band of Gosset

24. Biology and Biochemistry
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

25. Biology and Biochemistry
Biologically similar to wound repair
Myofibroblasts – nodules
Gelberman – myofibroblasts in nodules and fibroblasts with prominent microtubules in the fascia
Murell – compared fibroblasts in both tissues and found them identical Just more abundant in Dupuytren's

26. Biology and Biochemistry
Increased levels of fibroblastic growth factors in the diseased fascia
Macrophages – perivascular cuff early in disease
Basic Fibroblastic growth factor (bFGF)
bFGF – proliferation of myofibroblasts and endothelial cells which narrow the lumina of vs
Platelet derived growth factor (PDGF)
cellular signal for myofibroblast proliferation
increase rate of type III collagen synthesis
Transforming growth factor (TGF beta)
stimulates growth of mesenchymal cells, fibroblasts
increased deposition of extra cellular matrix

27. Pathogenesis Intrinsic theory- McFarlane 1974
Diseased cords are as a result of the pathologic changes in the normal fascia
Cords arise from defined fascial precursors and progress along predictable routes determined by normal fascial anatomy
Does not offer a rational explanation for the central cord commonly seen in Dupuytren’s

28. Pathogenesis Extrinsic Theory – Hueston 1985
The fibrotic process begins with nodules and progresses to cords
Nodules arise de novo by metaplastic transformation of fibrofatty tissue and later spread as cords just superficial to the palmar aponeurosis
Rational explanation for the presence of nodules, recurrence after fascial excision, lower recurrences after dermofasciectomy

29. Pathogenesis Synthesis Theory - Gosset’s 1985
Cords and nodules represent different forms rather than different stages of the disease process
Cords arise from palmar fascia and nodules de novo
Anatomic studies Strickland and Leibovic support the synthesis theory as the best reconciliation between the intrinsic and extrinsic

30. Murell’s Free Radical Hypothesis
Localized ischemia
Free Radical generation
Microvs narrow lumina thickened endothelial cells
Endothelial xanthine oxidase derived free radicals
Stimulate fibroblasts localized damage
Pericyte damage collagen deposition further ischemia
Increased Hypoxanthine concentration
Xanthine oxidase activity
1990

31. Unifying Pathogenesis Andrew 1991

32. Clinical Presentation
Anatomical Distribution
Skin Involvement
Contracture
Digital Allen’s Test
Maturity
General Condition

33. Anatomical Distribution
Normally Ulnar
One or more digit
Different stages of involvement

34. Skin Involvement

35. Nodules, Cords, Pits, Skin Shortening

36. Non Operative Management
External Fixation and Distraction
Progressive lengthening of the digital nv bundle
Easier access to the diseased cords after distraction in the fingers that are very contracted
Only useful in end stages
Long distraction time
Complications – infection, stiffness, pain, CRPS type I
Contractures recur quickly without fasciectomy

37. Non Operative Management
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

38. Operative Management Age General Health Motivation
Type of hand – Aesthetic , Workman’s
H/O CRPS
Type of involvement
Deformity and progression

39. Surgical Management
Formulation of a plan regarding the management of the skin, involved fascia, joints and extensor apparatus
Management of Skin
Incision
Longitudinal
Spiral cord – The nv bundle is pulled towards the centre and may lie transversely just under the skin

40. Skin Management

41. Skin Management 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

42. Surgical Management

43. 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

44. Skin Replacement

45. Skin Replacement

46. Skin Replacement Flaps Cross finger Seagull Dorsal transposition flaps
Dorsal Rotation Flaps
Flag Flaps

47. Contracted Fascia Management
Fasciotomy
Fasciotomy and grafting Extensive Dupuytren’s --- Firebreak
Fasciectomy
Segmental
Complete Longitudinal fasciectomy
Radical Palmar Fasciectomy
Dermofasciectomy

48. Contracted Fascia

49. Contracted Fascia

50. Contracted PIP Joint Gentle passive manipulation
40% peri articular adhesions which require GPM
Long standing contractures may produce joint changes requiring surgical release
Volar plate – check rein ligaments
Accessory collateral ligaments
Flexor tendon sheath release between A2-A4
Vascular compromise
Extensor apparatus – patients with 60 degree contracture, 80% will show central slip attenuation

51. Postoperative Rehabilitation
Very important
Commenced after early inflammatory phase (3-5 days)
ROM exercises, short periods, repetitive
Splinting, initial static for 2 wks, MCPJ deg. Flexion, PIPJ straight, DIPJ free then PIP splint at night – 8-10 wks.
Scar management

52. Complications 17-19 % 0verall Intra operative Nerve Injury
Digital circulation
Skin flap Thinning , Button hole
Post operative
Haematoma
Skin loss
Infection
Edema
Wound Dehiscence

53. Complications
Dupuytren’s Flare – Inflammatory reaction occurring 2-3 wks after the surgery
More common in women 20 %
Acute carpal tunnel syndrome
Redness, pain, edema, stiffness
Sympathetic blockade, oral steroids, carbamazapine
Reflex Sympathetic Dystrophy – 5 x more common in women (5 %)
Pain, edema, stiffness, vasomotor symptoms

54. Recurrence and Extension
Recurrence is the reappearance of disease in the area of previous surgery
26-80 %
Extension is the appearance of new disease in an area not subjected to surgery
Common causes of failure
Failure to remove all the involved tissues
Failure to correct PIP joint contractures at initial surgery

55. Recurrence
Failure to recognize central slip attenuation at initial procedure 80 % of patients with a 60 deg flexion contracture at PIPJ
Failure to recognize perivascular fibrosis leading to ischemia on full extension
Poor cooperation with hand therapy After excision of fascia haematoma and scarring is inevitable Vigorous hand therapy limits the effect of scarring