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Ebopras > Dupuytren Contracture > Flashcards

Dupuytren Contracture Flashcards

1
Q

What is the cause of Dupuytren disease?

A

It is usually familial disease with multifactorial causes. The tissue-level problem is a proliferative fibroplasias.

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2
Q

What are the diseases associated with Dupuytren disease?

A
  1. diabetes mellitus
  2. anti-convulsant therapy and epilepsy 3. chronic alcoholism
  3. HIV infection
  4. tobacco consumption
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3
Q

Is the disease related to work or trauma?

A

The disease has been noticed to increase in heavy manual workers or following injury to the hand.

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4
Q

Who gets this disease?

A

Typically Scandinavian or Northern European men (10:1 prevalence over women).

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5
Q

Where do they get it?

A

The most common fingers to get Dupuytren are the ring and small fingers.

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6
Q

What is Ledderhose disease?

A

Plantar fibromatosis.

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7
Q

What is Peyronie disease?

A

Penile fibromatosis.

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8
Q

Do these have anything to do with Dupuytren diathesis?

A

Yes. Dupuytren diathesis is the presence of a strong family history of Dupuytren disease associated with knuckle pads, Ledderhose or Peyronie disease. The patient often develops aggressive disease at a young age with a high likelihood of recurrence following surgery.

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9
Q

What are the risk factors in developing Dupuytren disease?

A
  1. family history
  2. other type of fibromatosis 3. early and aggressive onset 4. severe bilateral disease
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10
Q

What is Luck’s classification of the disease?

A

Three phases:
1. proliferative phase 2. involutional phase 3. residual phase

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11
Q

What is the difference between the collagen in normal fascia and that of the disease?

A

Normal fascia contains mostly type I collagen, whereas collagen in Dupuytren disease contains mostly Type III
collagen

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12
Q

What cell type is implicated in Dupuytren?

A

The myofibroblast.

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13
Q

What other molecules may play a role in the development of Dupuytren disease?

A

Transforming growth factors (TGF-B), platelet-derived growth factor, fibroblast growth factor.

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14
Q

Cytokines, which are hormone-like peptides, may be responsible for which process in humans that can lead to Dupuytren disease?

A

Signaling the transformation of fibroblasts into myofibroblasts.

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15
Q

Name the normal fascia and their pathological forms in Dupuytren disease.

A

r Pretendinous band becomes pretendinous cord. r Lateral digital sheet becomes lateral cord.
r Natatory ligament becomes natatory cord.

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16
Q

What other cords contribute to the disease?

A

Central and spiral cords.

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17
Q

What forms the spiral cord?

A

It is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson ligament.

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18
Q

What other ligaments in the hand are not affected by the disease?

A

r Superficial transverse ligament r Deep transverse ligament
r Cleland ligament
r Landsmeer ligament
Dupuytren Contracture 253

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19
Q

What causes metacarpophalangeal (MCP) joint flexion contracture in Dupuytren disease?

A

Pretendinous cord.

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20
Q

What causes proximal interphalangeal (PIP) joint flexion contracture in Dupuytren disease?

A

Spiral cord, lateral cord, and central cord.

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21
Q

What causes MCP adduction contracture in Dupuytren disease?

A

Natatory cords and the termination of the transverse fibers of the palmar aponeurosis.

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22
Q

Does the distal interphalangeal (DIP) get involved in Dupuytren disease? If so, how?

A

Yes, essentially by the retrovascular cord and to some extent by the lateral cord.

23
Q

What is the key thing to remember about natatory cords?

A

They prevent abduction of the fingers at the MCP joints.

24
Q

What causes neurovascular displacement in the disease?

A

The spiral cord.

25
Q

What is the histological hallmark of the disease?

A

The high cellularity. Notably, polyclonal in nature suggesting that the tissue is not truly neoplastic.

26
Q

What could it be caused by?

A

Local ischemia and production of free radicals.

27
Q

What are the two forms of the diseased fascia?

A

Cord and nodule.

28
Q

What is the histological feature of the nodule?

A

Dense collection of myofibroblasts.

29
Q

What are Garrod nodes?

A

An associated finding in Dupuytren disease: knuckle pads over the dorsum of the PIP joint.

30
Q

How should Garrod nodes be treated?

A

Local steroid injection or oral nonsteroidal anti-inflammatory drugs.

31
Q

What are the histological features of the cord?

A

Contains no myofibroblasts but highly organized collagen as seen in tendons.

32
Q

What causes cord contracture?

A

Myofibroblasts in the nodules account for active contraction.

33
Q

Where are nodules usually located?

A

Usually just distal or just proximal to the distal palmar crease.

34
Q

What can an area of skin dimpling alert the surgeon of in a patient with Dupuytren disease?

A

A spiral cord may exist, and the possibility that a digital nerve may be located in the immediate subcutaneous
position.

35
Q

What is the differential diagnosis for Dupuytren disease (including isolated nodules)?

A
  1. ganglion
  2. inclusion cyst
  3. epithelioid sarcoma
  4. camptodactyly
  5. trigger finger
  6. boutonniere deformity
36
Q

How does one differentiate a Boutonniere deformity from a severe PIP joint flexion contracture?

A

Hyperextension of the DIP joint may indicate that a Boutonniere deformity is present. If there is resistance to passive DIP joint when the PIP is passively extended, the oblique retinacular ligament is contracted and the lateral bands are held palmar to the PIP joint axis.

37
Q

If a patient has carpal tunnel syndrome and Dupuytren disease, can the two conditions be treated surgically at the same time?

A

Controversy exists. Nissenbaum and Kleinert believe that the conditions should be treated at separate times, while Michon, Gonzalez, and Watson advocated for simultaneous surgical treatment.

38
Q

What are the nonsurgical treatments for the Dupuytren disease?

A
  1. steroid injections
  2. splinting and skeletal traction
  3. ultrasound therapy
  4. laser therapy
  5. collagenase and enzymatic fasciotomy
39
Q

How successful is the nonsurgical treatment?

A

Recent evidence has shown collagenase injections to be a promising alternative to surgery. In early trials, the safety profile is promising and the recurrence rates after injections appear to be low. At the time of this writing, collagenase therapy is Food and Drug Administration-approved for Dupuytren contractures of both the MP and PIP
joints.

40
Q

What are the indications for surgery?

A
  1. MCP contracture of 30◦ or more
  2. any PIP contracture
  3. severe adduction contracture
41
Q

What is the tabletop test?

A

Described by Hueston, it simply tests the patient’s ability to place the palm flat on a tabletop. Once they cannot,
some surgeons recommend surgery.

42
Q

What are some of the functional tasks that a patient with Dupuytren contractures may complain of?

A

Retrieving an object from a pocket, wearing a glove.

43
Q

What are the three aspects to be considered in the surgical treatment of Dupuytren disease?

A
  1. Management of the skin.
  2. Management of the fascia.
  3. Management of the wound.
44
Q

What does management of the skin involve?

A

It involves the skin incision either transverse or longitudinal (linear, zigzag, or lazy S).

45
Q

What does management of the fascia involve?

A

Either can be used:
1. incision (fasciectomy)
2. local excision (regional fasciectomy)
3. wide excision (extensive radical fasciectomy)

46
Q

What does management of the wound involve?

A

The wound is sutured, left open, or skin grafted.

47
Q

What is percutaneous needle fasciotomy?

A

A technique first described by Cooper, it involves performing an aponeurotomy of the diseased fascia using a needle. Several percutaneous stab incisions are made in the cord using the needle to “cut” or puncture the cord in the palm and/or digit, while passive extension of the finger assists in releasing the contractures

48
Q

What are the results of percutaneous needle fasciotomy?

A

van Rijssen treated 88 rays by percutaneous needle fasciotomy (pnf ) and 78 rays by open limited fasciectomy. Follow-up was 6 weeks. The total passive extension deficit improved by 63% in the pnf group, and 79% in the limited fasciectomy group. The results favored the limited fasciectomy group with larger preoperative flexion contractures. The rates of major complications were 5% in the limited fasciectomy group, and 0% in the pnf group. The authors concluded that in cases of total passive extension deficit of 90◦ or less, pnf is a very good treatment option.

49
Q

What is dermatofasciectomy?

A

Wide excision of the involved palmar and digital skin and fascia combined with skin grafting.

50
Q

What are possible indications for skin grafting?

A
  1. Patients with Dupuytren diathesis.
  2. Patients with recurrent PIP joint contracture.
  3. Patients with primary, severe PIP contracture resulting in skin deficiency at closure once the joint has been restored to extension.
51
Q

What is the difference between extension and recurrence of the disease?

A

Extension refers to the postoperative appearance of the disease in an area of the hand not involved in the surgery.
Recurrence refers to postoperative appearance of the disease in the area of previous surgery.

52
Q

Mention some complications of the surgery.

A
  1. neurovascular bundle injury
  2. hematoma and skin necrosis
  3. joint stiffness
  4. reflex sympathetic dystrophy
  5. recurrent or uncorrected deformity
53
Q

What is the postoperative management?

A
  1. Operated hand usually splinted in extension.
  2. Wound care and frequent dressing changes.
  3. Active and passive range-of-motion exercises postoperatively.
  4. Splinting varies depending on the surgical technique used.
  5. PIP joint usually need 6 weeks of full-time splinting and at least 3 months of night splinting.

Ebopras (32 decks)

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