dupuytrens contracture

1. DUPUYTREN’S
CONTRACTURE
PRESENTED BY : DR ANIL KUMAR P
MODERATOR :DR NAGAKUMAR J S
PROFESSOR
DEPT OF ORTHOPAEDICS
SDUMC, kolar

2. HISTORY
• In 1831,Baron Guillaume Dupuytren described the condition of
palmar fascial contraction (Dupuytren disease)

3. DEFINITION
• It is a proliferative fibroplasia of the subcutaneous palmar
tissue, occurring in the form of nodules and cords, that may
result in secondary progressive and irreversible flexion
contractures of the finger joints.
• Other secondary changes include thinning of the overlying
subcutaneous fat, adhesion to skin, and later pitting or dimpling
of the skin.

4. • 5% of patients with Dupuytren contractures have similar lesions
in the medial plantar fascia of one or both feet, known as
Ledderhose disease
• 3% of patients have plastic penile induration, known as
Peyronie disease.
• Garrod nodules, “knuckle pads” are common on the dorsum of
the proximal interphalangeal joints.
• Patients with these associated findings are considered to have
a Dupuytren diathesis and are prone to progressive and
recurrent disease.

6. Epidemiology
• Age: Incidence increases with increasing age and
• peaks between 40-60 years
• Sex: Males > Females (10 times)
• Race: White Caucasians
• Geography: North European descent
• Genetics is Unclear (Autosomal dominant with variable
penetrance)
• Bilateral :45%
• Exact cause: Unknown

7. Associated with:
1. Diabetes mellitus
2. Cigarette smoking
3. Alcoholism and liver disease
4. HIV infection
5. Epilepsy: Anti-epileptic drug Phenobarbitone
6. Trauma
7. Manual labour
8. Rheumatoid disease
9. Plantar fasciitis
10.Peyronie disease

8. Pathology
• Dupuytren contracture begins with increased fibroblast
proliferation followed by type 3 collagen deposition resulting in
uncontrolled palmar fascia growth ultimately causing flexion
contractures.
• Myofibroblasts are the histologic hallmark of Dupuytren’s
contracture
• Increase in:
–Type III collagen, matrix metalloproteinase
–Lysyl oxidase, Transforming growth factor-β
–Glycosaminoglycans
• Increase in cellularity (fibroblasts).

9. PATHOGENESIS
• Local ischemia at the microvascular level increase in fibroblast
& related cell types
• Fibroblasts then organize themselves along Line of stress,
Cords causing Deformity
• Ischemia
• Free radicals
• Increased cells (fibroblasts)
• Increase fibroblast
• Vasoconstriction

10. Nodules & Cords
• Major forms of diseased tissues
• Two distinct histological tissues
NODULES
• Dense cellular collections of myofibroblasts: indicates centers of high
metaplastic activity.
CORDS
• No myofibroblasts
• Highly organised collagen structure similar to tendon
• Nodules produce the contraction by pulling the cords which expand
across the joints

11. • LUCK described 3 stages of progression of nodule:
1. Proliferative: Young nodules with non-stress aligned
fibroblasts, grows, displace subcutaneous tissue & fuses to skin
2. Involutional: Growth stops, Stress alignment of fibroblasts,
More collagen is produced , contraction of tissues
• Fascial hypertrophy
• Nodule cord units
3. Residual: Size reduces, Acelullar fibrous cords

12. PROGRESSION OF DISEASE
• The lesion usually begins on the ulnar side of the hand at the
distal palmar crease and progresses to involve the ring and little
fingers, these being affected more frequently than all other
digits combined.
• Metacarpophalangeal and proximal interphalangeal joint flexion
contractures gradually develop; their severity depends on the
extent and maturity of the fibroplasia.

13. Nodules, Pits, Skin Contractures

14. Patient comes with complains of - Fingers getting in the way with:
• Washing face
• Combing hair
• Putting hand in pocket
• Racquet sports
• Golf
• Putting hand in glove

15. Symptoms
• Tender nodule or progressive palmar cord development.
• May be painless, and may avoid care until joint motion reduced.
• Symptoms may be present bilaterally.
• Atrophic grooves or pits in skin signify adherence to the
underlying fascia.
• Tender knuckle pads over dorsal aspect of PIP joints--indicates
aggressive disease.

16. Positive Table top Test:
• The distance marked should be zero in a normal hand with a
negative table top test.

17. Dynamic flexion contracture:
• When MCP joint is at neutral,
the PIP joint contracture is
more.
• When MCP joint is flexed, the
deformity at PIP is reduced.
• This is attributed to the
Central Cord involvement.

18. Treatment
Nonoperative
• Collagenase (clostridial
collagenase histolyticum (CCH)
• External beam radiation(less
than 30 Gy).
• Steroid injection
Operative
• Subcutaneous fasciotomy ----
Scalpel or Needle
• Partial (selective) fasciectomy
• Complete fasciectomy
• Fasciectomy with skin
grafting
• Staged resection f/b external
fixation
• Arthrodesis
• Amputation

19. Operative Management
Indications:
• A Positive Table Top Test: correlates with
• MCP contracture of > 30-40°
Treatment of other digits on the same hand
• should be considered when their MCP contracture are 20-30° or
more.
• – PIP joint release if PIP joint contracture > 30°

20. • Important to distinguish true PIP joint contracture from apparent
contracture (due to spiral cord)
• MCP joint contracture is measured with PIP joint held in
extension
• PIP joint contracture is measured with MCP joint in flexion

21. • The least extensive procedure, subcutaneous fasciotomy, is
commonly used for elderly patients who are not concerned with
the appearance of the disease or in poor general health.(early
stages )
• Partial (selective) fasciectomy usually is indicated when only the
ulnar one or two fingers are involved:
• Fasciectomy with skin grafting may be indicated for young
people in whom the prognosis is poor
• Complete fasciectomy is rare and dangerous

22. • Amputation, although rarely necessary, may be indicated if
flexion contracture of the proximal interphalangeal joint,
especially of the little finger, is severe and cannot be corrected
enough to make the finger useful.
• A 40-degree flexion contracture usually is tolerated fairly well.
• Joint resection and arthrodesis procedure results in a shortened
finger but avoids the potential for recurrent proximal
interphalangeal joint contracture and a potential amputation
neuroma

23. Incision
• No incision should cross a flexion crease at right angles on
wound closure

24. • Make a zigzag or vertical incision over the deforming
pathologic structure
• Continue the incision proximally into the palm, avoiding
crossing the palmar creases at right angles
• Elevate the skin and underlying normal subcutaneous
tissue from the pathologic fascia from proximal to
distal
• Excise the pathologic fascia proximal to distal, taking
great care to isolate and protect the neurovascular
bundles of each finger

25. • Avoid entering tendon sheaths if possible because
bleeding into the flexor tendon sheaths may cause
adhesions
• Follow all the contracted fascial cords to their distal
insertions. Insertions may be into tendon sheaths, b
• all joints should permit full passive extensionone, and
skin
• 4-0 or 5-0 monofilament nylon

27. 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 grafting

28. Direct closure:
• Primary wound healing
• No need for skin grafts
• Simple post-op management
• Increased incidence of Hematoma and
• Skin flap necrosis

29. Postoperative Rehabilitation
• Drains usually are removed within 24 to 48 hours
after surgery
• If a hematoma is found elevating the skin, it should
be evacuated and the involved area of the wound
should be left open
• first dressing change is done 3 to 5 days after
• Commenced after early inflammatory phase (3-5 days)
• ROM exercises for short periods, repetitive

30. • Splinting:
• – Initially static for 2 weeks with MCP in 10-20° Flexion, PIP
straight and DIP joint free
• – After 2 weeks PIP splint at night for 8-10 weeks
• The patient is warned not to place the hand in a dependent
position for rest and not to soak the hand in hot water
• The resting pan splint is worn for 3 months after surgery.

31. Complications
Intra-operative:
• – Digital nerve division.
• – Hematoma formation.
• – Wound healing difficulties (flaps).
• – Vascular compromise of a digit.

32. Post-operative:
– Patient compliance.
– Reflex sympathetic dystrophy (flare reaction).
• Recurrence up to 63%.

33. Thanking you

34. video