Hand iSAWE 2

Diagnosis

• Dupuytren disease with MCP and PIP joint flexion contractures

Pathogenesis and pathoanatomy

• Fibroproliferative disorder of the palmar fascia driven by myofibroblasts, with increased type III collagen
• Luck stages are proliferative, involutional and residual
• Normal bands become cords, including pretendinous, spiral, natatory, lateral and retrovascular cords
• The spiral cord, formed from the pretendinous band, spiral band, lateral digital sheet and Grayson ligament, displaces the neurovascular bundle centrally and superficially

Demographics and risk factors

• Northern European ancestry, men in the fifth and sixth decades
• Autosomal dominant inheritance with variable penetrance
• Diabetes, alcohol, smoking and antiepileptic medication
• Dupuytren diathesis predicts recurrence, with early onset, family history, bilateral disease and ectopic lesions such as Garrod pads, Ledderhose and Peyronie disease

Examination findings

• Palpable nodules and cords, most often in the ring and little fingers
• Positive Hueston tabletop test when the hand cannot lie flat
• Measure MCP and PIP contractures with a goniometer
• Check digital sensation and perfusion before surgery

Management

• Observe painless nodules
• Surgery for an MCP contracture over about 30 degrees or any functionally limiting PIP contracture
• Percutaneous needle fasciotomy for MCP cords, with higher recurrence
• Limited fasciectomy is the standard operation
• Dermofasciectomy with full thickness skin graft for recurrence or diathesis
• Hand therapy and night extension splinting after surgery
• Complications include digital nerve and artery injury, wound problems, CRPS and recurrence

Related pages

• Dupuytren’s Disease