Hand 2nd deformity

Dupuytren’s Disease – Wrist & Hand

Definition

Dupuytren’s Disease is a benign proliferative disorder characterized by the formation of fascial nodules and contractures in the palmar fascia. This results in the development of pathologic cords that lead to finger flexion deformities.

Epidemiology

Age of onset: Typically presents in the 5th to 7th decade of life.
More common in men and Caucasians, with a higher prevalence in certain populations.

Pathophysiology

Etiology: Primarily genetic with an autosomal dominant (AD) inheritance pattern.
Risk Factors include:
- Alcoholism
- Diabetes Mellitus (DM)
- HIV
- Phenytoin therapy
- Pulmonary tuberculosis (T.B.)
- Dupuytren’s Diathesis
  age <50, white men, bilateral hands, family history, ectopic disease outside the palm including Ledderhose, Peyronies, Garrod pads شفوى ❓️Peyronie’s disease (dartos fascia of penis) 2-8%
  Garrod disease (knuckle pads) 40-50%
  Ledderhose disease (plantar fascia) 10-30%
Pathology:
- Myofibroblasts are the dominant cell type involved.
- The formation of nodules and cords within the palmar fascia, leading to deformities.
- Common cord locations:
  - Central Cord: Typically causes MCPJ (metacarpophalangeal joint) contracture.
  - Spiral Cord: Most important, often causes PIPJ (proximal interphalangeal joint) contracture.
  - Distal Cord: Associated with DIPJ (distal interphalangeal joint) contracture.
- Cords may be retrovascular (deep to the neurovascular bundle).

Clinical Presentation (C/P)

Age: Most commonly seen in middle-aged individuals.
Bilateral presentation is frequent.
Plantar fascia involvement: Can sometimes be associated with the condition.
Affect penile corpora causing penile contracture (Pyron ds)
Painful nodules: Most often affect the little and ring fingers.
Limited range of motion (ROM), particularly with finger extension.
Positive Hueston table top test: Inability to flatten the hand fully.

Differential Diagnosis (D.D.) of Claw Hand

Skin, m, tendons, N, joint

Ulnar nerve palsy
Klumpke’s paralysis
Median & ulnar nerve palsy
Volkmann’s ischemic contracture
Post-burn contracture
Neglected suppurative tenosynovitis
Rheumatoid arthritis (RA)
Poliomyelitis

Conservative Treatment (First-Line)

Range of Motion (ROM) Exercises: To improve flexibility and prevent further contracture.
Injections:
- Clostridial collagenase: Used for the lysis or rupture of the pathologic cords.
- complications
  minor
  edema/contusion, skin tear, pain are most common
  major (1%)
  flexor tendon rupture, CRPS, pulley rupture Mcq ❓️
  has low activity against type IV collagen (in basement membrane of blood vessels and nerves) explaining the low neurovascular complication rate شفوى ❓️ هل يؤثر على الأعصاب
- Steroid injections: To reduce inflammation.

Operative Treatment

Indications: Surgical intervention is required for flexion contractures of the MCPJ or PIPJ joints.
Methods: Mcq ❓️
- Percutaneous needle aponeurotomy تخريم followed by manipulation and night orthosis wear
- Limited Palmar Fasciectomy: Removal of only the diseased tissue. Z-plasty.
- Radical Palmar Fasciectomy: Excision of all diseased palmar fascia.
- Open Palm Technique: Transverse skin incision at the distal palmar crease, left open for delayed grafting.

Complications

Recurrence: Common in Dupuytren’s disease even after surgery. 20-50%. Mcq ❓️
Hematoma: Most common post-surgical complication.
Flap Necrosis: Potential complication following fasciectomy.
Flare Reaction (RSD): Reflex Sympathetic Dystrophy can occur postoperatively.
Neurovascular Injury: Risk due to the central and superficial displacement of cords during surgery.

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