Overview
- Benign fibroproliferative disease affecting the palmar fascia
Risk Factors
- Male (up to 10:1)
- Northern European (Viking) origin
- Alcohol
- Smoking
- Family history
- Manual work
- Diabetes
- Anti-Epileptic drugs
Aetiology
- Overriding genetic predisposition
- Autosomal dominant with variable penetrance
Contributory Theories
- Intrinsic
- Metaplasia of native fascia
- Extrinsic
- Subdermal origin which attaches to and involves fascia
- Free Radical Theory (more in vogue)
- Free radicals present in hypoxic tissues (diabetics, smokers, alcoholics, manual laborers)
- Cause cytokine release (PDGF, TNF-b, etc.)
- Cytokines induce transformation of fibroblasts to myofibroblasts
Histopathology
- Type 3 collagen
- Myofibroblasts
- Cytokine mediated (TNF; Fibroblast growth factor)
Pathologic Stages
- Proliferative Stage
- Nodule & pit formation
- Large myofibroblasts dominate
- Involutional Stage
- Cells align in the line of digits
- Ratio of type 3 to type 1 collagen increases
- Residual Stage
- Resultant scar-like cords
- Myofibroblast numbers decrease, leaving fibrocytes
Dupuytren’s Diathesis
- Severe Dupuytren’s characterized by:
- Strong family history
- Affliction of radial digits (thumb and index)
- Ectopic disease (penis - Peyronie’s, feet - Ledderhose)
- Garrod’s pads
- Bilateral disease
- Young presentation
Order of Digits Affected
- Ring > Little > Middle > Thumb > Index
Normal Anatomical Structures
- Bands are normal, cords are abnormal
Palmar Fascia
- Continuation of forearm fascia and Palmaris longus
- Function: Anchor skin and improve grip
Key Ligaments & Bands
- Pre-tendinous Band: Ends at distal palmar crease, in line with digits
- Spiral Bands: Bifurcation of pre-tendinous bands, lateral to digits
- Lateral Digital Sheet: Lies lateral to NV bundles in digits
- Grayson’s Ligament (Ground): Lies volar (towards ground) to NV bundle
- Cleland’s Ligament: Lies dorsal to NV bundle
- Vertical Fibres: Between palmar fascia and skin
- Natatory Ligament: Located in web spaces
- Scoog’s Fibres: Transverse fibres between NV bundles and palmar fascia
- Up to distal crease level
- Important in revision surgery (superficial dissection is always safe)
Pathologic Anatomy
Pits/Nodules
- Precursors of cord formation
- Lie over pre-tendinous bands
- Related to vertical fibres that anchor the skin
Cords & Contractures
- Pre-tendinous Cord
- Most commonly involved band causing MCPJ contracture
- Responsible for MCPJ contracture along with natatory cord
- Central Cord
- Extension of the pre-tendinous cord into the digit
- No NV displacement
- Spiral Cord
- NV bundle spirals around it and is displaced
- Lateral Cord
- From lateral digital sheet
- Displaces NV bundle medially (uncommon)
- Natatory Cord
- From natatory ligament
- Must be excised to complete correction at MCPJ level
- Retrovascular Cord
- Rare dorsal cord extending to DIPJ causing hyperextension
- Abductor Digiti Minimi Cord
- Only in little finger, displaces NV bundle medially
- Commissural Cord
Diagnosis
History
- Risk factors
- Degree of disability
- Previous surgery
- Features of Dupuytren’s diathesis
- Presence of pain (pain is unusual, beware if present)
Examination
- Quantify deformity
- Measure PIPJ with MCPJ flexed (cord crosses both joints)
- Measure MCPJ with PIPJ flexed
- Define cords
- Skin quality
- Previous scars
- Must do Digital Allen’s test in severe deformities pre-operatively
Differential Diagnosis
- Epithelioid Sarcoma: Rare, aggressive, not confined to fascia
- Subcutaneous Lesions: GCT, dermoid cysts, trigger finger, etc.
- Primary Joint Contracture
Surgical Planning
- Considerations
- Deformity correction feasibility
- Skin problems
- NV structure displacement
- Functional aims of the patient
Management
Non-Operative
- Splinting & Steroid injections not effective
- Mild disease should be managed non-operatively as recurrence is inevitable
Collagenase Injection (Xiaflex)
- Injection into the cord
- MUA the following day if no spontaneous rupture occurs
- Selectively attacks type 3 collagen
- Approved by NICE
- CORD 1 Trial (NEJM RCT): Beneficial for MCPJ
- CORD 2 Trial: Examined PIPJ (data pending)
- Limitations: Expensive, long-term results unknown (>3 years)
Operative Indications
- MCPJ deformity >30°
- PIPJ deformity >15°
- Symptomatic patient
Markers of Poor Outcome/Recurrence
- Significant PIPJ deformity (collateral ligament & volar plate contracture)
- Young patient (more aggressive disease, longer recurrence window)
- Dupuytren’s diathesis
- Revision surgery
Operative Options
Percutaneous Needle Fasciotomy
- Good for pre-tendinous cords
- Risk of NV bundle displacement in spiral/lateral cords
- Higher recurrence, but minimal invasiveness
Skin Incisions
- Brunner’s Incision (>60° angles)
- Straight with Z-plasties (60° angle = 75% more length)
- Open Palm (McCash): Leaves large skin defects open
Fasciectomy
- Partial/Regional Fasciectomy
- Workhorse procedure, good correction but eventual recurrence
- May require open wound management or grafting
- Segmental Fasciectomy
- Cords divided at multiple levels
- Lower morbidity, higher recurrence
- Reserved for elderly with low correction aims
- Radical Fasciectomy
- Rarely used, aims for total fascia excision
- Recurrence still occurs
Dermofasciectomy
- For revision cases or severe primary disease
- Excision of diseased tissue with midlateral incisions
- Full-thickness skin graft from cubital fossa
- Recurrence rate 10% (low)
Post-Op Protocol
- Plaster splinting with fingers straight
- Follow-up in 1 week: Wound check & splinting
- Splinting for 6 weeks
- Flexion exercises to prevent stiffness
- Night splinting up to 6 months
Salvage Surgery
- Amputation: Severe recurrent disease, low-demand patient
- Corrective Arthrodesis: Recurrent disease, poor soft tissues
Complications
- Intraoperative: NV damage, vascular spasm
- Postoperative: CRPS, haematoma, wound breakdown, infection, recurrence, loss of flexion
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