Dupuytren's Contracture

Question 1

what is the earliest sign of a dupuytren’s contracture?

Answer 1

fibroplastic hyperplasia and altered collagen matrix of palmar fascia

leads to

firm, thickened palmar nodule over MC head at the level of the distal palmar crease
this is proximal to MCP joint

Question 2

what happens after the development of the palmar nodule in dupuytren’s contracture?

Answer 2

palmar skin changes - e.g. thickening, tethering, puckering, pitting
with loss of mobility of overlying skin

Question 3

what happens to cause misalignment of finger in dupuytren’s contracture?

Answer 3

pretendinous cord formation
these are well-defined cords resembling tendon

Question 4

what happens after pretendinous cord formation in dupuytren’s contracture?

Answer 4

pretendinous cords may progress until they travel across MCP joint, causing MCP joint flexion contracture - so affected finger can no longer extend

this can then progress to PIP joint flexion contracture

note that the cords begin to contract over months to years

Question 5

what is dupuytren’s contracture?

Answer 5

result of progressive, fibrotic thickening of the longitudinal palmar fascia

Question 6

how does dupuytren’s contracture present?

Answer 6

fixed flexion deformity of 4th and 5th digit and contraction of MCP and IP joints

most cases are symmetrical and bilateral

Question 7

causes of dupuytren’s contracture?

Answer 7

idiopathic - commonest
diabetes
excess alcohol use with chronic liver disease
fmhx
aids
peyronie’s disease

Question 8

mx of dupuytren’s contracture?

Answer 8

conservative with physiotherapy and exercise
surgical management: fasciectomy with z-shaped scar (usually done to prevent recurrence)

Question 9

epidemiology of dupuytren’s contracture?

Answer 9

6x more common in men
peak onset 40-60y
most commonly affects ulnar digits

Question 10

what are similar clinical conditions to dupuytren’s contracture involving thickening of fascia in other body areas?

Answer 10

leddarhose disease - plantar fibromatosis
peyronie disease - penile fibromatosis
garrod nodes - fibromatossis of dorsal PIP joints

Question 11

what test can be done for dupuytren’s contracture?

Answer 11

hueston’s test - pt unable to lay palm flat on a tabletop

Question 12

if dupuytren’s is unilateral, what hand is usually affected?

Answer 12

right

Question 13

spectrum of symptoms for pt with dupuytren’s contracture?

Answer 13

reduced ROM and nodular deformity to complete loss of movement

Question 14

what is the nodule mostly composed of in dupuytren’s

Answer 14

type 3 collagen

Question 15

clinical sign in pt with dupuytren’s?

Answer 15

skin blanching on active extension of affected digits

Question 16

differential diagnosis of dupuytren’s?

Answer 16

stenosing tenosynovitis - often painful, a/w overuse or trauma
ulnar nerve palsy - a/w reduced movement/strength and loss of sensation
trigger finger - nodule present a/w finger motion

Question 17

how is dupuytren’s diagnosed?

Answer 17

CLINICAL

but need routine bloods to assess for RFs
no imaging needed but USS can be used for increased accuracy in applying intralesional injections

Question 18

mx of dupuytren’s?

Answer 18

depends on stage of presentation

if early and no functional disability - monitor + conservative
functional disability or rapidly progressive - more invasive treatment

Question 19

what is conservative mx for dupuytren’s?

Answer 19

hand therapy - keep hand active with exercises throughout day

injectable collagenase clostridium histolyticum (CCM) - sometimes used ine arly disease

radiotherapy/injections not recommended for early disease

Question 20

what is surgical mx for supuytren’s?

Answer 20

fasceictomy: excision of diseased fascia under LA/GA
indicated if functional impairment, MCP contracture >30degrees, any PIP contracture, rapidly progressive disease

Question 21

what are different types of fasciectomy in dupuytren’s?

Answer 21

Regional: entire cord is removed (most common)

Segmental: only short segments of cord are removed

Dermofasciectomy: cord and overlying skin are removed, to be followed by a skin graft

Closed fasciotomy: a less commonly performed procedure

Finger amputation: v. rarely required

Question 22

what is another term for closed fasciotomy?

Answer 22

percutaneous needle fasciotomy

Question 23

closed fasciotomy is indicated when in dupuytren’s?

Answer 23

benefit of being performed in outpatient setting under LA, so more suitable for co-morbid patients unsuitable for major surgery

Question 24

when is finger amputation done in dupuytren’s?

Answer 24

only ever considered in very severe cases where there has been a delay in presentation and failure of initial mx

Question 25

prognosis of dupuytren’s?

Answer 25

variable disease course
most eventually need surgery
post-operative recurrence is ~66%