1. OLD MAN’S CLAW HAND

2. DUPUYTRENS CONTRACTURE
Baron Guillaume Dupuytren
 PROLIFERATIVE FIBROPLASIA OF S/C PALMAR
TISSUE FORMING NODULES AND CORDS
RESULTING IN SECONDARY FLEXION
CONTRACTURES OF FINGER JOINTS

3. OTHER SECONDARY CHANGES
 THINNING OF OVELYING S/C FAT
 ADHESION OF SKINTO LESION
 PITTING OR DIMPLING OF SKIN
 KNUCKLE PADS ON DORSUM OF PIP JOINTS

4. ETIOLOGY
 AGE GROUP- B/W 50 AND 70
 MALESARE COMMONLYAFFECTED
 HEREDITY-AUTOSOMAL DOMINANT
PATTERN
 TRAUMA AND MANUAL LABOUR?
 VASCULAR INSUFFICIENCY AND
CIGRATTE SMOKING

5. Associated conditions
Epilepsy (42%)
Alcohol-induced liver disease
Smoking
Diabetes mellitus
Hypertension
IHD

6. PATHOANATOMY
FASCIAL COMPONENTS INVOLVED
 PRETENDINOUS BANDS
 SUPERFICIALTRANSVERSE LIGAMENT
 SPIRAL BANDS
 NATATORY LIGAMENTS
 GRAYSONS LIGAMENTS
 LATERAL DIGITAL SHEATH

7. Bands – Normal tissue Cords – Abnormal tissue

8.  The basis of Dupuytren disease lies in
the nodule and the cord, the pathologic
counterparts to the tendon and
pretendinous bands. Most often, a
nodule forms on either side of the distal
crease of the palm. Later, nodules may
form near the MCP joint or next to the
PIP joint of the thumb and fourth and
fifth digits..

9.  In the palm, contractures occur in the
pretendinous bands and natatory
ligaments, which are subsequently called
the pretendinous cord and natatory cord,
respectively.
 In addition, a contracture maybe formed
by the attachment of the transverse fibers
of the palmar aponeurosis, which is found
at the crease between the index finger
and the thumb.

10.  In the digits, normal fascial
structures, including the volar
superficial fascia and lateral digital
sheets, effectively become the central
cord and lateral cords, respectively

11. PATHOGENESIS
 Investigators have proposed several
hypotheses for the pathogenesis of Dupuytren
disease. Most of them agree the cords and
nodules are formed by fibroplasia and
hypertrophy of already existing palmar fascia
and subcutaneous fat.
 Research has shown that growth factors such
as basic fibroblast growth factor (FGF),
platelet-derived growth factor (PDGF), and
transforming growth factor-beta (TGF-â) may
signal the overproduction of the myofibroblasts
and/or myofibroblastic activity of the fibroblasts

12.  History
 A patient typically presents with a history
of progressive loss of range of motion
(ROM) of the affected finger(s)
 The fourth digit most commonly is
involved. The fifth, third, and second
fingers are involved in decreasing order of
frequency. Specifically, there is a
decreased ability to fully extend the MCP
joint(s); sometimes a decreased ability to
fully extend the PIP joint(s) is noted.

13.  The history may refer to an isolated
nodule in this area, initially somewhat
tender, which may have hardened and
then disappeared. Asking about functional
disabilities may elicit a history of certain
tasks that the individual can no longer
perform, such as grasping objects and
typing.
 No sensory deficits are reported unless
there is a concomitant pathology. The
condition is painless in its later stages.

15. CLINICAL FINDING
 PAINFUL NODULES
 DIMPLING OF OVERLYING SKIN
 DEFORMITY AND INTERFRERENCE
OF NORMAL FUCTIONING OF
HAND

16. Examination reveals a palmar skin nodule,
generally within the distal aspect of the
palm.
The nodularity generally is not tender to
palpation.
Puckering of the skin above the nodularity
may be noted. Overlying skin may be
adherent to the fascia, and a fibrous cord
can extend into the finger.
Flexion of the digit is normal for passive and
active ROM.

17. Conversely, extension is limited at the MCP and
sometimes the PIP joints of the affected digits.
This limitation in finger extension occurs when
testing passive and active ROM.
The ring finger (digit 4) is the most commonly
involved site, followed by the small finger (digit
5). Other digits may be involved, although less
commonly.
Loss of progressive flexion of the fingers in the
resting position from the radial to ulnar side
may be noted.
Although the patient may, because of the
contractures, have difficulty grasping objects,
strength is normal within the available ROM.
Sensation is typically normal.

18. PROGNOSIS
POOR PROGNOSTIC FACTORS
HEREDITY—FAMILY HISTORY
INWOMEN IT BEGINS LATEAND
PROGRESSES SLOW
ALCOHOLICSAND EPILEPTICS
BILTERAL

19. TREATMENT

20. OBSERVATION
 WHEN CONTACTURE IS PROGRESSING SLOW
 NOT DISABLING
 REVIEW EVERY 3 MONTHS

21. RADIOTHERAPY
 EFFECTIVE ONLY DURING EARLY
FIBROPLASTIC PHASE

22. SURGERY- BEST KNOWNTREATMENT
 1. SUBCUTANEOUS FASCIOTOMY
 2.PARTIAL(SELECTIVE) FASCIECTOMY
 3.COMPLETE FASCIECTOMY
 4. FASCIECTOMYWITH SKIN GRAFTING
 5.AMPUTATION

23. 1.SUBCUTANEOUS FASCIOTOMY
 PREFFERED IN ELDERLY,ARTHRITIS
PATIENTSAND IF GENERAL CONDITION IS
POOR
 RESULTSARE GOODWHEN LESION IS
MATURE
 MAY BE DONE AS PRELIMINARY STEPTO
FASCIECTOMY
 72% RECURENCE RATE

24. CONTD…SUBCUTANEOUS FASCIOTOMY
 TECHNIQUE- LUCK
 DISEASED FASCIAL BANDS IS CUTWITH A
SHARP INSTUMENT PASSED S/CTHROUGH
A PUNCTUREWOUND

25.  AFTERTREATMENT- PRESSURE DRESSING
IS USED FOR 24 HOURS,THEN SMALLER
DRESSING
 ACTIVE MOTION OF HANDAND FINGERS
ENCOURAGED

26. 2.PARTIAL(SELECTIVE)
FASCIECTOMY
 COMMONLY DONE PROCEDURE
 LESS MORBIDITY
 LESS COMPILCATIONS
 50% CHANCE OF RECURRENCE
 ONLY MATURE DEFORMINGTISSUE IS
EXCISED

27.  ZIGZAG INCISION IS MADE OVERTHE
PATHOLOGIC STRUCTURE.INCISION
EXTENDED PROXIMALLY AVOIDING
CROSSING PALMAR CREASESAT RIGHT
ANGLES.SKIN IS ELEVATEDAND S/CTISSUE
IS SEPERATED FROM PATHOLOGIC TISSUE
 PATHOLOGICTISSUE EXCISED.
 Z-PLASTYWILL BE DONE

29. 3.COMPLETE FASCIECTOMY
 RARELY DONE BECOZ IT IS ASSOCIATED
WITH HAEMATOMA,JOINT
STIFFNESS,DELAYED HEALING AND
RECURRENCE.

30. 4. FASCIECTOMY WITH SKIN
GRAFTING
 INDICATED FORYOUNGER PEOPLEWITH
EPILEPSY,ALCOHOLISM.
 SKIN AND UNDERLYING ABNORMAL
FASCIAARE EXCISED AND FULLTHICKNESS
ORTHICK SPLIT SKIN GRAFT IS APPLIED.

31. AMPUTATION
 IF FLEXION CONTRACTURESOF PIP JOINTS
ARE SEVERE

32. POST-OP
 STATIC DORSAL FOREARM SPLINT
 WITH A DISTAL COMPONENT OVER
DORSUM OF FINGERSTOWHICH THEYARE
STRAPPED IN EXTENSION
 MIN 3 MONTH SPLINT
 FINGER EXERCISES

33. Notable sufferers

34. Plantar fibromatosis-Morbus
Ledderhose
 benign nodules grow at the arch of the foot
 cords can develop but not as frequently as
with Dupuytren's contracture
 Initially these nodules are usually painless but
as they grow they can cause considerable
pain when walking

36.  same therapies apply
 But feet have to carry a lot of weight and
while a patient might be able to avoid the use
of an operated hand, this is usually much
more inconvenient with an operated foot
 Ledderhose nodules seem to grow to bigger
sizes than Dupuytren nodules

37.  While contraction is usually observed at the
hand (Dupuytren's contraction), it is not
typical for Morbus Ledderhose though it
might happen
 . Development of cords seems to be less
dominant for Ledderhose.
 Possibly weight and continuous exercise keep
feet and toes straight or the Ledderhose
nodules reside in a more static area and are
thus subject to less pulling forces than the
nodule's in the hand.


38.  Thus therapies to straighten toes again are
less important for Morbus Ledderhose
 the focus is more on reducing the size of the
nodules, reducing pain and inflammation,
and maintaining the ability to walk.
 Therefore therapies for Ledderhose and
Dupuytren's are probably as similar as foot
and hand: similar, but not the same.

39. Thank you
&
Happy Teacher’s day