Dupuytren's Disease Flashcards Preview

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Flashcards in Dupuytren's Disease Deck (22):

what is Dupuytren's disease?

  • A Benign Proliferative disorder CHARACTERISED by FASCIAL NODULES and CONTRACTURES of the hands

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Can you describe the epidemiology of Dupuytren's?

  • AUTOSOMAL Dominant
  • 5-7th decade of life
  • 2:1 M:F
  • Highest incidence in  Caucasian males European descent
    • Linked to Diabetes Mellitis
    • Alcholism
    • Epilepsy
    • HIV


What is its pathology?

  • MYOFIBROBLASTS are the dominant cell type found histologically

  • Cytokine mediated Transformation of normal fibroblasts into mylofibroblasts 

  • Increase in type 3 collagen to type 1 

  • The disease orginates in longitudinally orientated fascial structures 

  • Early proliferative phase characterised by high no of immature fibroblasts & myofibroblasts in a whorled pattern- hostological nodule


What 3 stages of disease have been described?

By Luck ( himself)!!!!- NB LUCKy Pir

1)PROLIFERATIVE- hypercellular, large myofibroblasts, minimal extracellular matrix

2)INVOLUTIONAL -dense myofibroblast network increase collagen 3 cf 1

3)RESIDUAL - myofibroblasts DISAPPEAR leave FIBROCYTES as predom cell


What does it using present with?

  • A nodule in the palmar fascia maybe painful and progress insidiously -> diseased cords and finally digitally flexion contractions beginning at MCP and progressing distally
  • Reduced rom MCPJ/PIPJ/DIPJ

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what has duptyren's been associated with?

  • ETOH xs
  • DM
  • epilepsy
  • chronic pulmonary disease
  • TB
  • HIV


Can you describe/draw the normal fascial structures that become involved?


  • SPIRAL BAND- palmodigital transition( underneath NV bundle)
  • NATATORY BAND- palmodigital transition


  • GRAYSON LIGAMENT (palmar to NV bundle, passes flexor sheath to the skin, maintain digitial skin position)
  • LATERAL DIGITAL SHEET- formed from fibres form natatory & spiral band

Cleland ligaments relatively not involved in D.

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What does the disease change the bands into?

Can you name them all?

Diseased CORDS

  • Central
  • Spiral
  • Natatory
  • Lateral 
  • Retrovascular


What is not involved in the disease process?

CLELAND ligaments (nb Clevland)


Can you name the palm cords?

Pretendinous cords


What is the SPIRAL CORD made up from?


(NB Simon Phillips Never Loves Grapes)

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What does the spiral cord lead to ?

  • PIPJ contraction
  • NV bundle = As travels under NV bundle it displaces it MIDLINE and SUPERFICIAL( VOLAR) increased risk during surgical resection
  • Best predictors of displacement = PIPJ flexion contracture ( 77% PPV), Interdigital soft tissue mass (71% PPV)
  • Clinically the most important contracture as pipj flexion warrants surgery

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What makes up the natatotory cord?

What is its function?

  • Develops from fibres of natatory ligament, just under commissure skin
  • causes Web space contracture


What is the central cord in the phalanx?

What does it cause?

  • The distal  extent of the pretendinous cord
  • Fibres fro cord extend and insert into flexor sheath around PIPJ -> MCPJ contraction
  • Not involved with neurovascular bundle

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What makes up the retrovascular cord?

What does it cause?

  • Can arise dorsal to the NV bundle taking origin fro the proximal phalanx and inserting onto the distal phalanx
  • DIPJ flexion


What are the best predicts of displacement of nv bundle ?

PIPJ flexion contraction -77% PPV

interdigital Soft tissue mass 71% PPV


What are the signs of D?

  • Nodule in pretendinous band of palmar fascia
  • involves commonly small or ring finger
  • Postive Heuston Table top test- look for mcpj/pipj contracture
  • look for bilateral involvement and ectopic
  • Ledderhose disease- plantar fascia
  • Peyronie's disease- dartos fascia of penis
  • Garrod's disease ( kuckle pads)

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What are the tx options?

Non op

  • Range of motion exercises
  • largely unsuccessful
  • Emerging COLLAGNASE injections- derived from clostridium hystolyticum are promising.
  • Causing lysis and rupture of cords but swelling, bruising, flexor tendon rupture early results better for MCPJ and contractors less than 50 degrees


What are the indications for surgery?

  • MCP contracture >30 degrees
  • Any PIPJ contracture
  • Painful nodules ARE NOT INDICATIONS for surgery


What are the surgical options?

  • Needle cordotomy- for frail patients- risk of nerve injury
  • Regional palmar fasciectomy - Brunner incision, V to y or sequential z plasties can be used to lengthen the skin- removed disease tissue only in digits with preservation of skin- iatrogenic nerve injury 7%. early rom day 5-7, night tiemextension brace/splint 
  • Dermofasciectomy with full thickness skin graft or z plasty, v-y advancements or healing by secondary intention- recurrence is less with this procedure as remove skin
  • Open palm technique- McCash- approach transverse skin incision at level of distal palm crease ( see pic)- may be left open with/ wout delayed wound healing- low risk of haematoma formation- useful older pts at risk of stiffnes/low risk of complx due to lack of haematoma formation
  • Recurrent disease- dermofascectomy+FTSG / arthrodesis/ amputation maybe required

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What are the complications ?

  • Haematoma - most common -> FLAP Necrosis
  • Wound complications
  • Digital ischaemia
  • Post op swelling
  • Recurrence- long term 50% less with dermofasciectomy
  • Flare reaction -pain w diffuse swelling. hyperthesia, stiffness
  • NV injury- due to displaced by spiral cord- central adn superficial. identify prior to excising cord 
  • CRPS
  • skin loss
  • amputation


is physio important?

Yes with active rom and static splinting to maintain extension