DUPUYTREN’S CONTRACTURE

Defination:
This is a condition characterised by a flexion deformity of one or
more fingers due to a thickening (nodular hypertrophy) and
shortening of the palmar aponeurosis (superficial palmar fascia)

Epidemiology
 About 60 per cent of patients give a family history.
 The condition is inherited as an autosomal dominant trait
 It is more common in males than females;
 the prevalence increases with age,
 Onset at an early stage usually means aggressive disease.
 There is a high incidence in epileptics receiving phenytoin
therapy;
 associations with
 Diabetes,
 Smoking,
 Alcoholic cirrhosis,
 AIDS and
 Pulmonary tuberculosis
 There is a contentious and weak association with injury
to the hand.

Pathology
 The essential problem in Dupuytren’s disease is proliferation of
myofibroblasts;
 After an initial proliferative phase, fibrous tissue within the
palmar fascia and fascial bands within the fingers contracts,
 Causing flexion deformities of the MCP and PIP joints.
 Fibrous attachments to the skin lead to puckering.
 The digital nerve is displaced or enveloped, but not invaded, by
fibrous tissue. Occasionally the plantar aponeurosis also is
affected.

Clinical feature:
 The patient – usually a middle-aged man
 Complains of a nodular thickening in the palm.
 Gradually this extends distally to involve the ring or little finger.
 Pain may occur early on but is seldom a marked feature.
 Often both hands are involved, one more than the other.
 The palm is puckered, nodular and thick.
 If the subcutaneous cords extend into the fingers they may
produce flexion deformities at the MCP and PIP joints.
  Sometimes the dorsal knuckle pads are thickened (Garrod’s
pads).

Similar nodules may be seen on the soles of the feet (Ledderhose’s

disease).
There is a rare, curious association with fibrosis of the corpus
cavernosum (Peyronie’s
disease).

Dupuytren’s contracture must be distinguished from

 skin contracture (where the previous laceration is usually
obvious),
 tendon contracture (in which the finger deformity changes with
wrist position)
 PIP joint contracture (in which there may be a history of
clinodactyly or joint injury).

Treatment –
no surgery is needed unless the contracture progresses to functional
impairment.
Surgical
A. Operation is indicated
If the deformity is a nuisance or rapidly progressing.
(In particular, PIP joint contractures can become irreversible.)
B. The aim is
Reasonable, not complete correction.
Surgery does not cure the disease, it only partially corrects the
deformity

C. Operative procedures are

complete fasciectomy – Only the thickened part of the fascia is excised

(is usually unnecessary).
needle fasciotomy’ – An isolated cord across the front of the MCP joint
can be managed by dividing the contracture under local anaesthetic
with a bevelled needle.

If the disease is more extensive, the affected area is approached

through a longitudinal or a Z-shaped incision and, after carefully
freeing the nerves and blood vessels, the cords are excised. Skin
closure may be facilitated by multiple Z-plasties. This has the dual
effect of improving the deformity and, if recurrence occurs, preventing
a longitudinal wound contracture. The palmar section of the wound can
be left open; it will soon heal with dressings. This makes skin closure
easier and allows any haematoma (which may predispose to
recurrence) to escape.
After operative correction a splint is applied, and removed after a few
days for active motion exercises. Night splinting for a few months may
reduce recurrence.
If there is severe skin involvement (particularly in surgery for recurrent
disease),
if there is a strong family history, or if the patient is particularly young,
then skin grafting should be considered.
Amputation or Arthrodesis – occasionally, for severe, recurrent disease
in the little finger.

Superficial Fibromatosis (Palmar, Plantar, and Penile Fibromatoses)

Deep-Seated Fibromatosis (Desmoid Tumors)
The presence of hemosiderin in these lesions suggests hemorrhage from
tears
severity depends on the extent and maturity of the fibroplasias
Concomitant involvement of the plantar fascia, the fascia of the penis, or
both occurs in less than 3% of individuals with Dupuytren disease.

Correction of is
myofibroblast the MCP
the joint is cell
dominant more predictable
type than contracture.
in Dupuytren the PIP
Myo + Fibroblast
This is a contractile cell with increased type 3 collagen, possibly
originating from a transformed perivascular smooth muscle cell.
The Dupuytren fibroblast also has higher levels of a smooth muscle
actin and contractility than a normal fibroblast. Most investigators now
agree that in Dupuytren contracture the subcutaneous nodules and
cords are formed by fibroplasia and by hypertrophy of already existing
fibers of the palmar fascia. Millesi theorized that the pathological tissue
arises only through changes in the existing fibers of the palmar fascia
and not by the formation of new tissue. Luck suggested that the
subcutaneous nodules develop first, and cords form proximally in
response to intermittent stress resulting in contractures. According to
this concept,
the nodules progress through proliferative, involutional, and residual
stages.
In the proliferative stage, the nodules are young, non–stress aligned
fibroblasts that expand and displace the subcutaneous tissues and fuse
to the skin. The nodules typically appear around the distal palmar
crease over the metacarpophalangeal joint and distally over the
proximal interphalangeal joint, but never over the distal
interphalangeal joint.

The nodules eventually stop growing and begin to contract in the

involutional stage. Stress alignment of the fibroblasts occurs, and more
collagen is produced. Nodule contraction places tension on the normal
fascia proximally, producing fascial hypertrophy and nodule-cord units.
In the residual phase, the nodules decrease in size and may become
acellular fibrous cords.
nodules and cords do not represent two stages of the disease, but
rather two forms originating in two different tissues, the subcutaneous
fat and palmar fascia.
Hueston postulated that the nodules develop subcutaneously and only
later may involve the palmar fascia and overlying skin. Nevertheless,
contractures of the metacarpophalangeal and proximal interphalangeal
joints and displacement of digital neurovascular bundles result from
predictable patterns of fascial cord involvement.
The fascial structures that may become involved in the
fibroproliferative process have been clearly outlined by McFarlane (Fig.
72-3).
Thomine described a longitudinally oriented fascia located dorsal to
the neurovascular bundle, which he termed the retrovascular cord. This
structure often is involved in the disease and may be implicated as a
cause for recurrent proximal interphalangeal contractures.
The Cleland ligament generally is believed to be spared. The
pretendinous cord nearly always is responsible for primary contracture
of the metacarpophalangeal joint. It may attach to the distal palmar
crease skin, base of the proximal phalanx, or the tendon sheath at this
level, or it may extend to attach to the flexor tendon sheath over the
middle phalanx or the skin in this area. A spiral cord occurs when four
normally existing structures (pretendinous band, spiral band, lateral
digital sheet, and Grayson ligament) become diseased. The spiral cord
runs dorsal to the neurovascular bundle proximally and volar to it
distally. When the spiral cord is contracted, the neurovascular bundle is
drawn toward the midline of the finger (Fig. 72-4). Neurovascular
displacement is found most commonly on the ulnar aspect of the little
and ring fingers, and tedious dissection is required to prevent digital
nerve injury.

Robert M. McFarlane, - major contributions to our understanding of Dupuytren's

contracture.
division of cords (fasciotomy)
removal of palmar fascia (fasciectomy).
The site of onset is the fibrofatty layer between the skin and deep structures of the palmar
surface of the hand
Named after Baron
Guillaume Dupuytren
who described the
condition in 1831.
He attributed it to
holding the reins of the
horse for many years.
This was found not to be
the disease into three phases has been widely accepted: proliferative phase characterized
by cell proliferation “with no purposeful arrangement,” involutional phase in which
fibroblasts show alignment along tension lines, and residual phase in which tissue is
largely acellular and tendon-like.