# Hand Contractures - Dupuytren's ## Clinical Scenario A 62-year-old man of Northern European descent presents with progressive inability to flatten his right hand. He has palpable cords in the palm extending to the ring and small fingers with 60-degree MCP joint contracture and 40-degree PIP contracture of the ring finger. He is unable to place his hand flat on a table. ## Questions & Model Answers Risk factors for Dupuytren's disease: 1) Northern European/Celtic ancestry (Viking disease), 2) Male gender (7:1), 3) Age >50 years, 4) Family history (autosomal dominant with variable penetrance), 5) Diabetes mellitus, 6) Alcohol consumption, 7) Smoking, 8) Manual labour (controversial), 9) Epilepsy/anticonvulsants, 10) HIV infection. Pathological anatomy: The disease affects the palmar fascia and its extensions. Key structures: 1) Pretendinous bands become cords (cause MCP contracture), 2) Spiral band becomes spiral cord (wraps around neurovascular bundle), 3) Lateral digital sheet becomes lateral cord, 4) Natatory ligament becomes natatory cord, 5) Grayson's ligament may become involved. The spiral cord is dangerous - displaces the neurovascular bundle centrally, superficially, and proximally. **Key Points:** - Northern European ancestry - Spiral cord displaces neurovascular bundle - MCP contracture from pretendinous cord - PIP contracture harder to correct Treatment indications: 1) MCP contracture >30°, 2) Any PIP contracture, 3) Positive table-top test, 4) Functional impairment. Treatment options: 1) Needle aponeurotomy/percutaneous fasciotomy - office procedure, divide cord percutaneously, quick recovery, higher recurrence (50% at 5 years), best for MCP contractures, 2) Collagenase injection (Xiaflex) - enzymatic dissolution, inject then manipulate 24-48 hours later, better for isolated MCP cords, less effective for PIP, 3) Limited fasciectomy - surgical excision of diseased fascia, gold standard, lowest recurrence (20% at 5 years), longer recovery, 4) Dermofasciectomy - for recurrent disease, excise skin and fascia, full-thickness skin graft. For this patient: limited fasciectomy would be appropriate given MCP and PIP involvement. **Key Points:** - MCP >30° or any PIP = surgical indication - Limited fasciectomy lowest recurrence - Needle aponeurotomy high recurrence but quick recovery - PIP contractures harder to correct - manage expectations Surgical technique for limited fasciectomy: 1) Incision planning - Bruner zigzag incisions prevent longitudinal scar contracture, transverse palmar incisions at distal palmar crease, 2) Skin flaps - full thickness, preserve skin vascularity, 3) Identify and protect neurovascular bundles - start proximal where anatomy is normal, trace distally, the spiral cord displaces NV bundle centrally and superficially so approach from lateral side initially, 4) Systematic excision - excise pretendinous cord, natatory cord, spiral cord, lateral cord as needed, preserve A1 and A2 pulleys, 5) Release contracted joints - release MCP and PIP joint capsules if residual contracture after cord excision, 6) Wound closure - avoid tension, Z-plasties lengthen skin, may leave open wound in palm to heal by secondary intention (McCash technique), 7) Splint in extension. Rehabilitation is critical for PIP contracture correction. **Key Points:** - Bruner incisions prevent scar contracture - NV bundle displaced by spiral cord - careful dissection - May need joint release after cord excision - McCash open palm technique useful Fasciectomy complications: 1) Neurovascular injury (3-5%) - digital nerve laceration from spiral cord displacement, digital artery injury, manage with immediate repair or graft if recognised, 2) Skin necrosis (2-5%) - from excessive tension, thin flaps, vascular compromise, manage with local wound care, skin grafting if needed, 3) Haematoma - meticulous haemostasis essential, can cause skin necrosis, 4) Infection (rare) - standard wound care, antibiotics if cellulitis, 5) Stiffness - more common with PIP involvement, aggressive hand therapy essential, 6) CRPS (complex regional pain syndrome) - early recognition, hand therapy, pain management, may need stellate ganglion block, 7) Flare reaction - acute inflammatory response, tender swelling, occurs 1-3 weeks postop, treat with steroids and hand therapy, 8) Recurrence - disease in operated area, 9) Extension - disease in new area. Prevention: careful surgical technique, protect NV bundles, avoid tension on closure, early mobilisation. **Key Points:** - Nerve injury most common surgical complication (3-5%) - Spiral cord displaces NV bundle - key anatomical point - Flare reaction occurs 1-3 weeks postop - CRPS requires early recognition and multimodal treatment Recurrence management: Definition: Recurrence = disease returning in previously operated area, Extension = new disease in unoperated area. Incidence: 20% at 5 years after limited fasciectomy, higher after needle aponeurotomy (50% at 5 years). Risk factors for recurrence: 1) Young age at presentation (<50 years), 2) Dupuytren's diathesis, 3) Bilateral disease, 4) Family history, 5) PIP involvement, 6) Multiple digit involvement, 7) Aggressive disease biology. Treatment options for recurrence: 1) Repeat fasciectomy - more difficult due to scarring, higher complication rate, still effective, 2) Dermofasciectomy - excise diseased skin and fascia, full-thickness skin graft (from forearm or groin), significantly lower re-recurrence rate (8% vs 46%), 3) Amputation - rare, for severe recurrent disease with stiff painful finger that impairs hand function, 4) PIP joint fusion - for fixed PIP contracture. **Key Points:** - Recurrence 20% at 5 years post-fasciectomy - Dermofasciectomy with FTSG for recurrent disease - Diathesis patients have higher recurrence risk - Amputation rarely needed for severe recurrence Dupuytren's diathesis: A constellation of features indicating aggressive disease phenotype with higher recurrence and extension risk. Diathesis features (Abe criteria): 1) Young onset (<50 years), 2) Bilateral disease, 3) Positive family history, 4) Ectopic disease - Garrod's knuckle pads (PIP dorsal thickening), Peyronie's disease (penile fibromatosis), Ledderhose disease (plantar fibromatosis). Scoring: 0-2 points = low diathesis, 3-4 = moderate, 5+ = high (severe). Clinical implications: 1) Counsel patients about high recurrence risk (up to 70% long-term), 2) Consider more aggressive initial treatment - dermofasciectomy rather than limited fasciectomy, 3) Avoid needle aponeurotomy (high recurrence), 4) Earlier intervention may not prevent progression, 5) May need multiple procedures over lifetime, 6) Consider newer treatments under investigation (radiation, anti-TGF-β). For this patient: assess for diathesis features and counsel regarding long-term disease management. **Key Points:** - Diathesis = young onset + bilateral + family history + ectopic disease - High diathesis = 70% recurrence long-term - Consider dermofasciectomy in diathesis patients - Lifelong disease management expectation ## Exam Tips **Opening Statement:** This patient has Dupuytren's disease with ring finger MCP and PIP contractures meeting surgical criteria. I would perform limited fasciectomy with careful protection of the neurovascular bundle, which is displaced by the spiral cord. **Common Pitfalls:** - Spiral cord displaces NV bundle - highest risk structure - PIP contracture correction often incomplete - counsel patient - Extension splinting critical postoperatively