==== 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