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==== PIPJ in Dupuytren's Disease (Thurston) =====
2004-03-14

PIPJ: fingers > 45 deg flexion need secondary release (Ritchie JHSB 2004)

Sources of contracture:
  - accessory collateral ligament
  - volar plate
  -  checkrein ligament
  - transverse retinacular ligament
  - flexor tendon sheath

PIPJ release in DD (Paul Smith)
  - Central slip attenuation test
   - wrist maximum flexion
   - MCPJ maximum flexion
  - Rate of central slip attenuation - 80% with 60 degree PIPJ flexion
  - Look for tight conjoined lateral bands

Steps
  - Fasciectomy
  - Release volar contracture - volar plate or mobilization
  - Check for instability between extreme motion
  - Check central slip attenuation


==== Dupuytren's Contracture (from RTF notes) ====
Author: Alphonsus Chong 

Overview
 Proliferative Fibroplasia involving fascia of palm and digits leading to nodules, cords and contractures

Epidemiology
	• 	True incidence unknown - influenced by geography
	• 	Males predominantly (M:F, 10:1) - typically white caucasian of north european descent
	• 	extremely rare under 13 years of age
	• 	More common in temperate zones
	• 	More common in Northern Europeans, Scandinavians

Pathology:

Etiologic factors
	• 	multifactorial with genetic factors of primary importance
	• 	some factors:
	1 	traumatic - increased incidence a/w occupational hand trauma (vibration)
	2 	Neoplastic - immunocytochemical studies show relationship between sarcoma and DC; growth factors involved - FGF, TGFalpha, EGF
	3 	Genetic - AD with variable penetrance
	4 	?autoimmune component - T-cell mediated HI disorder; controversial
	5 	nordic theory - "viking disease" to modern europeans: celts, caucasians of northern europe descent
	6 	Risk factors: Diabetes Mellitus, Chronic alcoholism (believed to be related to liver involvement - lipid metabolism), epilepsy (?medication related), Chronic pulmonary disease, HIV infection, heavy smoker

Molecular biology and pathophysiology
	• 	Similarities between DC nodules and wound healing (based on immunocytochemistry and cell culture tests); BUT DC is sporadic and progressive 
	• 	Myofibroblasts (MF)-
	? 	characteristics of both fibroblasts and smooth muscle cells
	? 	origin uncertain - likely to be modulated contracture fibroblast 
	? 	contractile - PG; lysophosphatidic acid
	? 	alpha- smooth muscle actin
	? 	Features differentiating it from fibroblasts:
	? 	larger
	? 	indented nucleus
	? 	cytoplasmic actin microfilaments
	? 	macrophage source of GF and free radicals
	• 	ECM - synthesis and deposition of fibronectin (important in MF-MF and cell-stroma binding) leads to transmission of cellular contraction; increased PG, collagenespecially type III:I
	• 	Mechanical strain leads to cell culture proliferation 

Presentation

Initially presents with nodule in the palmar fascia
  * Nodule with or without palmar fibrosis
  * Cord
  * Associations
    * Ledderhose disease (plantar) 5-20%
    * Peyronies diesease (penile) 2-4%
    * Garrod's pads (PIPJ dorsum) 1-44%

Clinical types
  * Typical - bilateral in 50%, if unilateral mor likely on Rt; ulnar side: RF>SF>MF
  * Atypical -
    * race, gender irrelevant, FH absent
    * h/o RA/DM
    * develops after hand surgery or trauma
    * single sided

Dupuytren's diathesis
	• 	Young patient with severe disease
	• 	recurrent even after surgery
	• 	associated with palmar knuckle, plantar and penile fibromatosis
	• 	no family history
	• 	radial side
	• 	ectopic progression

Differential diagnoses
	• 	isolated trigger finger
	• 	Palmar induration
	• 	isolated digital dupuytren's

Non-surgical Management
	1 	Calcium channel blockers
	2 	Collagenase - big trial
	3 	Radiation
	4 	Intralesional steroids
	5 	Intralesions gamma interferon
	6 	External distraction - e.g. Messina's TEC device - few advantages, increased complications

Surgery when indicated
	1 	Severity of contracture
	1 	Hueston's table-top test
	2 	MP joint flexion contracture => 30 degrees
	3 	any IPJ flexion contracture
	2 	Infection of web space or flexor pits

Surgical options
	1 	Fasciotomy
	2 	Partial fasciectomy
	3 	Total fasciectomy
	4 	Dermafasciectomy - for Dupuytren's diathesis
	5 	Open palmar fasciectomy - McCash
	6 	Arthroplasty
	7 	Amputation - only if all else has failed; mainly for reasons of hygiene

== Choosing a surgical option ==

  * I am most familiar with partial fasciectomy. It works well, and lasts. [[jnl:leafblad2019]] reported a single surgeon experience of needle aponeurotomy vs collagenase vs open fasciectomy. At 5 years, reintervention rate for OF was 4% vs (55-60% for NA and Co). Cumulative costs was lower than Co, but higher than NA.



Complications of surgery
	• 	Recurrence 2-60%
	• 	Skin necrosis
	• 	hematoma
	• 	neurovascular injury
	• 	infection
	• 	digital flexion

Historical Notes
  * 1614 - Felix Platter (Swiss physician) - Stonemason's Hand - flexor tendon contracture
  * 1787 - Cline - Palmar fasciotomy
  * 1831 - Guillaime Dupuytren's lecture at Hote Dieu (Parisian Surgeon) - detailed normal and abnormal anatomy of plantar fascia; subsequently published work

References
  - Hand Secrets
  - Mc Cash
  - HSU2
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