Dupuytren’s Disease

Definition

Fibroproliferative disorder of palmar aponeurosis

Aetiology

Murrell’s Theory of Pathogenesis

• Initiating event is microvascular ischaemia
• Ischaemia itself leads to conversion of
  • ATP toHypoxanthine
  • Endothelial Xanthine Hydrogenase to Xanthine Oxidase
• Xanthine Oxidase catalyses reaction
  • Hypoxanthine to Uric Acid
  • Which gives off OH- (hydroxyl free radicals)
• OH- stimulate fibroblast proliferation
  • Increasing Type III Collagen
• Fibroblasts strangle microvessels
  • Vicious Cycle
• ATP: Hypoxanthine: Uric acid + OH-: fibroblast proliferation: microvascular strangulation

Epidemiology

• 5% Caucasians
• Especially Vikings
• Rare Blacks & Asians
• M:F – 5:1
• 20% Male > 65 years

Risk Factors

• Local ischaemia
  • DM
  • Smoking
  • Trauma (including fractures of the wrist)
  • Occupation? (weight of evidence against it)
  • Alcoholic cirrhosis
  • Anti-epileptic medication (phenobarbitone)
  • HIV
• Genetic
  • Vikings – Anglo-Saxon/ Celtic origin
  • AD with variable penetrance

Anatomy

• Key to dissection
• Normal structures (bands) become cords & nodules
• Mnemonic “bland bands become crazy cords”

Pretendinous Bands

• Volar & midline to neurovascular bundle
• Form from palmar aponeurosis as it travels to digits
• Splits at MCPJ
• Some into skin
• Rest deep to neurovascular bundle as spiral band

Natatory Ligament

• Transverse & superficial to neurovascular bundle at web space
• Attached to flexor sheath/ skin
• Almost always involved

Spiral Bands

• Termination of pretendinous band
• Pass deep then lateral to neurovascular bundle

Lateral Digital Sheet

• Lateral condensation superficial fascia

Grayson’s Ligament

• Volar to neurovascular bundle
• Arises tendon sheath
• Inserts to lateral digital sheet

Cleland’s Ligament

• Dorsal to nv structures & same origins as Grayson’s ligaments
• Not involved

Transverse Fibres of the Palmar Aponeurosis

• “Skoogs fibres”
• Superficial to nv bundles at level MC heads
• Never involved
• Where you should look to trace nv bundles

Cords

• Central, Spiral, Lateral, Natatory
• Form along normal fascial pathways
• Tighten up
• Follows three dimensional anatomy
• Neurovascular bundle spirals around spiral cord
• Between distal palm crease & proximal crease finger
• Coalesce into one

Spiral Cord

• Formed by
  • Pretendinous band (medial to nv bundle)
  • Spiral Band (deep)
  • Lateral Digital Sheet (lateral)
  • Grayson’s ligament (superficial)

Pathology

Myofibroblasts

• Contractile cell
• Occur elsewhere (GUT)
• But not normally in palmar fascia
  • Originate as Perivascular Fibroblasts
• Convert secondary to local hypoxia
  • Mainly in nodules
• None in cords
• Responds to cell growth factors
  • PDGF/ FGF/ TGF B

Type III Collagen

• Increased secondary to ↑ cell density
• Controversial role

Abundant Fibroblasts

• Cords only
• Peri-arterial
• Organised along stress lines
• Occluded microvessels

Classification

Tubiana, by total flexion deformity of MCP, PIP and DIP joints

Stage	Total flexion deformity
N	Nodule without contracture
1	0 to 45 degrees
2	45 to 90 degrees
3	90 to 135 degrees
4	Over 135 degrees

Original publication Tubiana R. Evaluation of deformities in Dupuytren’s disease. Ann Chir Main. 1986;5(1):5-11.

History

• M>F – 7:1
• Right > Left
• RF > LF > MF > thumb > IF
• Tender nodules beyond distal palmar crease
• Painless fixed flexion deformity with disability
• Nodules, cords, pits

Dupuytren’s Diathesis

• Aggressive Disease: rapid progression & marked contractures
  • Young males
  • Significant family history
  • Multiple digits
  • Bilateral
  • Garrod’s Nodes (dorsal thickening of knuckle pads at PIPJ vs carpet layers at MCPJ)
  • Lederhose Disease
  • Peyronie’s Disease

Examination

• Palpable nodules and cords, ring and little fingers most often involved
• Goniometer measurement of MCP and PIP flexion deformity
• Hueston table top test positive when the palm cannot lie flat
• Skin pitting and blanching on finger extension
• Ectopic disease with Garrod knuckle pads, Ledderhose plantar fibromatosis and Peyronie disease
• Digital sensation and perfusion before surgery, especially in recurrent disease
• Thumb and first web space involvement

Investigations

• Clinical diagnosis, imaging not required
• US can confirm a nodule when the diagnosis is uncertain
• Blood glucose and liver function tests when diabetes or alcohol excess suspected
• X-ray when PIP joint arthritis is suspected

Differential Diagnosis

• Trigger finger
• Camptodactyly
• Post traumatic PIP joint contracture or boutonnière deformity
• Ulnar nerve palsy clawing
• Ganglion, epidermoid cyst or giant cell tumour of tendon sheath
• Epithelioid sarcoma
• Palmar callus

Treatment

Don’t Operate If Negative Table Top Test

• Don’t operate if nodule is painful – can trigger surrounding tissue & ↑ proliferation
• On occasion may need to operate if deep skin folds & pits cause repeated maceration & infection

Non-operative

• No proven benefit
  • Corticosteroids (to nodules & Garrod’s pads – Ketchum 1991)
  • Occupational Therapy
  • Allopurinol
  • 5-FU
  • Vitamin E
• Patient Education

Operative

Hueston’s “Table Top” Test

• Palm unable to touch table when trying to place hand flat on table
• If FFD of PIPJ & MCPJ able to hyperextend & allows palm to touch table then this is a –ve test
• Positive when MCPJ fixed flexion deformity > 40°?

MCPJ fixed flexion deformity

• easily correctable (see below)
• Often becomes troublesome with FFD > 30°
• Generally correctable at any degree of FFD

PIPJ fixed flexion deformity

• difficult to correct
• 30° fixed flexion deformity usual end result
• Hence McFarlane (1990) advocates
  • Release of PIPJ only if fixed flexion deformity > 30°
• Preoperative splint?

Three Technical Considerations

• Incision
• Fasciotomy/ fasciectomy
  • Fasciotomy
  • Segmental fasciectomy
  • Selective fasciectomy
  • Radical fasciectomy
• Wound closure

“Operation is dissection of the neurovascular bundles”

Skin Options

• Direct Closure ± Flaps
  • Longitudinal with Z-plasty
    • Midline longitudinal
    • Points at creases in midlateral line passing to midline
    • Angle 60° to longitudinal axis
    • Allows dissection from palm to finger
    • Does not allow wide dissection in palm: ↓ postoperative haematoma
  • Transverse
    • Used in palm when 2-3 rays involved
    • Can be combined with longitudinal incisions
    • Simple, good exposure & rapid healing
    • Skin necrosis & ↑ postop haematoma
  • Brunner ± VY plasty
    • Popular
    • Can do lazy Brunner (lazy “S”)
    • Zig-zag prevents scar contracture
    • However difficult to design flaps with finger contracted & flap difficult to construct with intimate proximity of diseased fascia
• Dermofasciectomy
  • Skin excision
  • Full thickness flaps
  • Less recurrence
  • Graft failure
• McCash Open Technique
  • Transverse mid palm wound at distal palmar crease
  • Leave open but review regularly
  • Allows haematoma to drain
  • Closes by contraction (takes 3-5/52)

Fascia Options

• Fasciotomy/ Segmental Fasciectomy
  • Limited procedure with cord divided or short portion of fascia excised
  • Partial or complete correction
  • Elderly or mild disease
  • Can be performed as outpatient procedure
• Selective Fasciectomy
  • Only Dupuytren’s tissue excised – leave normal looking tissue
  • Most popular technique
  • Mainstay
  • Subclinical disease may progress but often does not warrant further surgery
• Radical Fasciectomy
  • Excision of normal & diseased fascia
  • Less popular now
  • Still get recurrence
  • For those with Dupuytren’s diasthesis?

Wound Closure

• Options
  • Suture
  • Graft
  • Leave open
• Principle is closure without tension as this predisposes haematoma & wound breakdown

Release of PIPJ FFD

• Volar capsule/ volar plate released proximally at pars flaccida
• Checkrein Ligament (at proximal end of volar plate) released
• Accessory Collateral Ligaments (“sides of the wheelbarrow”) released
• Then pass along volar portion of collateral ligaments (ie “remove the arms off the wheelbarrow”)
• Then can release one collateral ligament if still tight

Management of Recurrence

• Revision
  • Allen’s Test Finger
  • Test Sensation
  • High risk neurovascular bundle injury
  • Selective fasciectomy & graft
  • PIPJ fusion if severe
• Amputation of finger if
  • PIPJ fixed flexion deformity > 90°
  • Insensate
  • Pain
  • Dysvascular

Complications

• 20%
• Classic triad
  • Haematoma
  • Infection
  • Skin loss
• Neurovascular bundle injury
  • Start dissection of nerve proximally
• Recurrence 50%
  • Dupuytren’s in a surgically treated field
• 15% need repeat operation
• RSD

Prognosis

• Progressive in most, at an unpredictable rate
• Recurrence at 5 years about 85% after needle fasciotomy and 21% after limited fasciectomy (van Rijssen)
• Recurrence at 5 years about 47% after collagenase (CORDLESS)
• MCP contractures correct more completely than PIP contractures
• Dupuytren diathesis predicts early recurrence and extension

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.