Alphonsus Chong's Personal Wiki

2004-03-14

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

Sources of contracture:

1. accessory collateral ligament
2. volar plate
3. checkrein ligament
4. transverse retinacular ligament
5. flexor tendon sheath

PIPJ release in DD (Paul Smith)

1. Central slip attenuation test
2. wrist maximum flexion
3. MCPJ maximum flexion
4. Rate of central slip attenuation - 80% with 60 degree PIPJ flexion
5. Look for tight conjoined lateral bands

Steps

1. Fasciectomy
2. Release volar contracture - volar plate or mobilization
3. Check for instability between extreme motion
4. Check central slip attenuation

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

• I am most familiar with partial fasciectomy. It works well, and lasts. 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

1. Hand Secrets
2. Mc Cash
3. HSU2