Ghazi Rayan
DEFINITION
Dupuytren disease (DD) is a fibroproliferative disorder that affects primarily the palmar fascial complex of the hand, with occasional secondary involvement of other areas of the hand as well as remote tissues.
It is an unparalleled condition that clinically and pathophysiologically resembles no other known ailment.
Although physiologically DD bears a resemblance to the processes associated with normal wound healing, the perpetual and progressive proliferation and abnormal collagen deposition with resultant tissue contracture is astonishing.
There have been attempts to classify DD under other headings such as inflammatory and neoplastic disorders; however, its uniqueness places it in a class of its own.
ANATOMY
The radial, ulnar, and central aponeuroses, palmodigital fascia, and digital fascia are elements of the palmar fascial complex.14
The radial aponeurosis has four components:
The thenar fascia, which is an extension of the central aponeuroses
The thumb pretendinous band, which is small or absent
The distal and the proximal commissural ligaments
The ulnar aponeurosis has three components:
The hypothenar muscle fascia, which is an extension of the central aponeurosis
The pretendinous band to the small finger, which is consistent and substantial
The abductor digiti minimi confluence
The central aponeurosis is the core of DD activity and has a triangular shape with a proximal apex (FIG 1A).
Its fibers are oriented longitudinal, transverse, and vertical.
The longitudinal fibers fan out as the pretendinous bands to the three central digits. Each pretendinous band bifurcates distally and each bifurcation has three layers. The superficial layer inserts into the dermis, the middle layer continues to the digit as the spiral band, and the deep layer passes almost vertically dorsally toward the flexor tendon and its digital sheath.
The transverse fibers make up the natatory ligament (NL) located in the distal palm and the transverse ligament of the palmar aponeurosis (TLPA). The TLPA is proximal and parallel to the NL (FIG 1B) and lies deep to the pretendinous bands. Its distal, radial extent is the proximal commissural ligament. The TLPA gives origin to the septa of Legueu and Juvara, which protect the neurovascular structures and provide an additional proximal pulley to the flexor tendons.
The vertical fibers of the central aponeurosis are the minute but strong vertical bands of Grapow and the septa of Legueu and Juvara (FIG 1C,D), which lie deep to the palmar fascia. There are eight septa that form seven fibro-osseous compartments3 of two types: four flexor septal canals that contain the flexor tendons and three web space canals that contain common digital nerves and arteries, and lumbrical muscles. These septa are inserted in a soft tissue confluence that consists of five structures: A1 pulley, palmar plate, sagittal band, inter-palmar plate ligament (IPPL; FIG 1D,E), and septum of Legueu and Juvara.
The palmodigital fascia encompasses a number of fascial structures, including the terminal fibers of the pretendinous bands, the spiral bands, the beginning of the lateral digital sheet, and the NL. The middle layer of the bifurcated pretendinous band spirals about 90 degrees and the peripheral fibers run vertically adjacent to the metacarpophalangeal (MCP) joint.
FIG 1 • A. The central aponeurosis is the core of Dupuytren disease activity and has a triangular shape with a proximal apex. B. The transverse fibers make up the natatory ligament (NL) located in the distal palm and the transverse ligament of the palmar aponeurosis (TLPA). C. There are eight septa of Legueu and Juvara that form seven fibro-osseous compartments of two types: four flexor septal canals that contain the flexor tendons and three web space canals that contain common digital nerves and arteries, and lumbrical muscles. (continued)
FIG 1 • (continued) D. Interpalmar plate ligament and septum of Legueu and Juvara. E. There are three interpalmar plate ligaments radial (to the left), central, and ulnar (to the right). These form the floor of the three web space canals. They continue distally deep to the neurovascular bundle and NL and emerge distal to this ligament and contribute to the formation of the lateral digital sheet. The proximal fibers of the NL run in a transverse plane, but the distal fibers form a U that continues longitudinally along both sides of the digit, forming the lateral digital sheet. The lateral digital sheet therefore has deep and superficial contributions from the spiral band and NL.
The digital fascia surrounds the neurovascular bundle in the digit, and this includes the Grayson ligament (palmar), the Cleland ligaments (dorsal), the Gosset lateral digital sheet laterally, and possibly fibers from the check-rein ligaments medially and dorsally that were described previously as Thomaine retrovascular fascia.
PATHOGENESIS
In DD normal bands become diseased cords,11 and Dupuytren nodules and cords are pathognomonic of the disease.12
A nodule usually appears first, followed by the cord.
The cords involve the palmar, palmodigital, or digital regions and progressively shorten, leading to joint and soft tissue contracture.
The Grapow vertical bands become microcords, leading to thickening of the skin, which is one of the earliest manifestations of DD.
Skin pits develop from the first layer of the split pretendinous band.
The pretendinous cord develops from the pretendinous band and is the most common cord in DD. It leads to MCP joint flexion deformity and often extends distally, contributing to the digital cords. The pretendinous cord may bifurcate distally with each branch extending into a different digit, forming a commissural Y cord (FIG 2).
The vertical cords, or diseased septa of Legueu and Juvara,2 are short and thick. They are connected to the pretendinous cord and extend deeply in between the neurovascular bundle and flexor tendon fibrous sheath.
Extensive palmar fascial disease is encountered in severe conditions and affects larger areas of the palm, leading to diffuse thickening of many components of the palmar fascial complex.
The spiral cord has four components: the pretendinous band, the spiral band, the lateral digital sheet, and the Grayson ligament. It is encountered most often in the small finger.
In the palm, this cord is located superficial to the neurovascular bundle. Distal to the MCP joint, it passes deep to the neurovascular bundle and in the digit it runs lateral to the neurovascular bundle as it involves the lateral digital sheet and again becomes superficial to the neurovascular bundle as it involves the Grayson ligament.
Initially the cord spirals around the neurovascular bundle, but as it contracts, the cord straightens and the neurovascular bundle spirals around the cord.
The distorted anatomy of the neurovascular bundle, which is displaced medially and centrally, becomes at risk of injury during surgery.19
The natatory cord develops from the NL, converting the Ushaped web space fibers into a V shape, resulting in contracture of the second, third, and fourth web spaces.
This cord extends along the dorsal lateral aspect of the adjacent digits and is best detected by passively abducting the digits and at the same time flexing one digit and extending the other at the MCP joints.
The most commonly encountered digital cord is the lateral cord, followed by the central and spiral cords. These are responsible for proximal interphalangeal (PIP) joint flexion deformity.
The central cord is an extension of the pretendinous cord in the palm.
The lateral cord originates from the lateral digital sheet and attaches to the skin or to the flexor tendon sheath near the Grayson ligament. The lateral cord leads to contracture of the PIP joint but can also cause a distal interphalangeal joint contracture.
FIG 2 • A,B. Pretendinous cord and a nodule in the palm in line with the ring finger causing metacarpophalangeal flexion contracture. C. Two pretendinous cords in the palm in line with the small and ring fingers causing metacarpophalangeal and proximal interphalangeal flexion contracture of the small finger. A small proximal commissural cord in the first web space is also present. D. Diffuse Dupuytren palmar fascial disease is present with nodular thickening in the entire palm.
The abductor digiti minimi cord, also known as the isolated digital cord, takes origin from the abductor digiti minimi tendon, but may also arise from adjacent muscle fascia at the base of the proximal phalanx.
It courses superficial to the neurovascular bundle, and infrequently entraps and displaces the bundle toward the midline.
It inserts on the ulnar side of the base of the middle phalanx but may attach on the radial side or have an additional insertion in the base of the distal phalanx, causing a distal interphalangeal joint contracture.
The distal commissural cord develops from the diseased distal commissural ligament, which is the radial extension of the NL. The proximal commissural cord originates from the proximal commissural ligament, which is the radial extension of the TLPA.
Both of these cords cause first web space contracture.
The thumb pretendinous cord originates from the thumb pretendinous band and causes thumb MCP joint flexion deformity, which is uncommon.
NATURAL HISTORY
DD has three clinical phases: early, intermediate, and late.13
Skin changes with loss of normal architecture and skin pitting characterize the early phase.
Nodules and cords form during the intermediate phase.
Contractures mark the late phase, with the MCP joint most frequently affected, followed by the PIP joint.
PATIENT HISTORY AND PHYSICAL FINDINGS
The classic DD patient is a Caucasian man with a positive family history. The condition is bilateral and progressive and may extend to the digits, leading to their contracture.
Palmar involvement usually precedes disease extension into the digits, but the disease may begin and remain in the digits.
The ring finger is the most commonly involved digit, followed in order of frequency by the small, middle, and index finger and last by the thumb.
DD may affect areas outside the palmar surface of the hand.
Ectopic disease can be either regional in the upper extremity or distant in other parts of the body.
Garrod nodes are different from knuckle pads, occur on the dorsum of the hand, and are almost always limited to the finger (FIG 3).
FIG 3 • A Garrod node over the dorsum of the proximal interphalangeal joint.
Distant ectopic DD affects the plantar fascia and male genitals.
Patients said to express a Dupuytren diathesis or genetic predisposition typically have faster and more severe development of the condition.
Positive family history
Young age of onset
Ectopic sites of fibromatosis such as the dorsal digital area (Garrod nodes), plantar fascia (Ledderhose disease), and male genitals (Peyronie disease)
DIFFERENTIAL DIAGNOSIS
Non-Dupuytren disease15
Occurs in a diverse ethnic group, is unilateral and nonprogressive, usually involves a single digit, and frequently follows trauma or surgery
Patients with this disease rarely require surgical treatment. Confusing this with DD will produce contrasting epidemiologic data.
Epithelioid sarcoma
Occupational thickening and callus formation that mimic Dupuytren nodules
Palmar subcutaneous soft tissue lesions, such as localized pigmented villonodular synovitis, palmar ganglions, and inclusion cysts
Stenosing tenosynovitis without triggering can be associated with thickening and adherence of the skin to the underlying flexor tendon sheath.
Prominent flexor tendons can be confused with pretendinous cords because of attenuation of annular pulleys, as seen in rheumatoid arthritis.
NONOPERATIVE MANAGEMENT
No treatment is necessary for non-Dupuytren disease.
Observation is appropriate for nonprogressive DD with minimal contracture and without compromise of function.
Surgical treatment for minor disease or pitting can result in a disease flare and must be avoided.
Basic science research has shown the potential of certain local agents in the treatment of DD. These include calcium channel blockers, nifedipine, and verapamil16 for early stages and collagenase1 for advanced stages of the disease.
Steroid injection of nodules has been used to suppress the disease.
SURGICAL MANAGEMENT
Surgery is the most widely used treatment method for symptomatic and severe DD.
Outpatient surgery offers substantial savings and should be used in an otherwise healthy patient with moderate hand involvement.
Local, regional, or general anesthesia can be used depending on the procedure performed.
Flexion contractures of the MCP joint of greater than 30 degrees and PIP flexion contractures of 15 degrees interfere with function and, in the presence of a well-developed cord, are indications for surgical treatment.
The outcome after surgery for MCP joint contracture is more successful than that for PIP joint contracture.
PIP joint check-rein release is indicated if 40 degrees of residual flexion is present after conventional fasciectomy.
Procedures
Percutaneous Fasciotomy
Percutaneous fasciotomy is indicated for palmar cords in elderly unhealthy patients.
This technique carries a higher risk for complications when performed in the thumb than in the digits.
In severe cases, this technique may be useful as a preliminary procedure before definitive removal of diseased tissue.
Injuries to flexor tendons and digital nerves as well as chronic regional pain syndromes have been reported after percutaneous releases.
Open Palm Fasciectomy
This method was first used by Dupuytren, who left the transverse palmar incision wound open after fasciotomy.
This method is indicated for extensive involvement of the palmar fascia and if primary closure is not possible and skin grafting is not desired.
Satisfactory results with this method continue to be reported in the literature,7,10,20 including less pain, better motion, and low rates of complication. The primary disadvantage is prolonged postoperative wound healing.
Partial Fasciectomy
Partial fasciectomy is the excision of the diseased tissue with preservation of normal-appearing fascia.
Other terms for this procedure are selective, regional, or limited fasciectomy.
Partial fasciectomy remains the most widely used technique for treatment of DD among hand surgeons today. It is associated with a lower recurrence rate than fasciotomy.
Dermofasciectomy
Dermofasciectomy involves excision of skin and diseased tissue simultaneously followed by grafting of the skin defect.8
Dermofasciectomy is the procedure of choice for recurrent or aggressive disease with marked adherence of skin to underlying diseased cords. It was reported to have lower recurrence rates compared to other surgical techniques even for recurrent disease.9
Extensive Fasciectomy
Extensive fasciectomy involves a wide, generous fasciectomy of diseased tissue involving most of the palmar fascial complex.
This can be combined if necessary with partial fasciectomy in the digits.
This technique is indicated when broad involvement of the palmar fascial complex is present.
The NL and TLPA may be involved in severe DD and these can be included in the extensive fasciectomy.
After extensive fasciectomy, the skin sometimes can be closed primarily. If a defect is present, the wound can be skin grafted or left open.
Total or radical fasciectomy entails removal of the entire diseased and normal palmar fascia with or without excision of the overlying skin.
This highly morbid, radical approach is not warranted.
Positioning
The patient is positioned supine and the hand is placed on a hand table with the shoulder abducted 90 degrees.
A padded pneumatic tourniquet is placed on the arm as proximally as possible. The upper extremity is exsanguinated and the tourniquet is inflated to 250 mm Hg.
Approach
The most commonly used incision is the Brunner zigzag incision (FIG 4A).
A midline longitudinal incision that is closed with multiple Z-plasties can be also used (FIG 4B).
Transverse palmar incisions can be used for the open palm method or for removal of extensive palmar fascial complex disease.
Local rotation flaps sometimes should be used to cover exposed flexor tendons or neurovascular structures, and the remaining secondary defect can be grafted with full-thickness skin.
FIG 4 • A. Partial fasciectomy through a zigzag Brunner incision. B. A longitudinal incision closed with multiple Z-plasties.
TECHNIQUES
PERCUTANEOUS FASCIOTOMY
Local anesthesia is used.
A tourniquet is not necessary.
Select the point of fasciotomy adjacent to the cord.
Use a no. 11 blade held vertically (TECH FIG 1).
Make a stab wound and turn the blade horizontally to cut the cord while the digit is manually extended.
A gratifying snap is felt and the finger should extend.
TECH FIG 1 • The no. 11 blade is used to incise the midline cord to improve the proximal interphalangeal joint contracture in this elderly patient.
OPEN PALM FASCIECTOMY
Make a transverse incision in the middle of the palm and extend it if necessary to the digits as a zigzag Brunner incision.
Undermine the skin flaps and identify the diseased tissue.
Carry the dissection proximally until a transition between normal and diseased fascia is identified.
Isolate the neurovascular structures from the diseased tissue and protect them.
Release the diseased tissue proximally; dissection is followed distally and excised.
Leave the transverse incision open to heal by secondary intention but close any extensions of the original incision into the fingers.
Apply nonadherent gauze to the wound and immobilize the hand in a forearm-based splint with the fingers in extension.
PARTIAL FASCIECTOMY
Make a zigzag Bruner incision; it may extend from the proximal palm to the digital pulp in cases of palmar and digital disease.
Undermine the skin flaps by careful dissection to separate relatively normal dermis from the diseased tissue. This can be difficult in recurrent cases. Make every effort not to buttonhole the flaps.
It is better to leave diseased tissue in the dermal flap rather than thinning the flap too much and running the risk of buttonholing the flap.
TECH FIG 2 • A. The neurovascular structures are dissected and protected during surgery. B. An excised specimen showing pretendinous (PC), vertical (VC), natatory (NC), nodule (N), and lateral (LC) cords. C. With a spiral cord, care must be taken to prevent injury to the digital nerve and vessel, which are intertwined with and spiraled around the diseased cord. D. A local flap is rotated to cover neurovascular structures. E. Skin shortage in the small finger was covered with a full-thickness skin graft from the volar wrist.
Identify the neurovascular structures, dissect them from the diseased cords, retract them, and protect them during the entire procedure (TECH FIG 2A).
Begin the dissection proximally in the palm until a transition between relatively normal and diseased fascia is identified.
Carry the dissection in a proximal-to-distal direction.
Transect the pretendinous cord proximally and follow the cord distally, dividing all connections to adjacent normal fascia.
If present, include in the excised specimen a vertical cord from the diseased septa of Legueu and Juvara and a natatory cord from the diseased NL (TECH FIG 2B).
Special attention must be given to a spiral cord (TECH FIG 2C) to prevent injury to the digital nerve and vessel, which are intertwined with and spiraled around the diseased cord.
If the diseased tissue is confined to the palm in the form of a pretendinous cord, the distal end of the cord can be seen inserted in the flexor tendon sheath distal to the MCP joint. The cord can be excised at this level.
If the diseased tissue extends to the digit, follow the digital cord into the finger.
Pretendinous cord extension in the digit can be in the form of lateral, central, or spiral cord.
The digital cord must be dissected in the finger with great care because of its proximity to the neurovascular bundle.
Identify and release the distal insertion of the digital cord.
Release the tourniquet and coagulate bleeders with a bipolar forceps.
After adequate hemostasis is achieved, close the wound without a drain.
If skin shortage is present, perform full-thickness skin grafting.
If the neurovascular bundle or flexor tendons are exposed, a flap may be rotated to cover these structures, and skin grafting is done for the secondary defect (TECH FIG 2D,E).
A palmar plaster splint with the digits in the corrected extended position is used for 1 week or less.
DERMOFASCIECTOMY
Plan the incision by mapping the area of diseased tissue and skin with a marker. The remaining exposure is done through a zigzag Brunner incision that extends from the dermofascial island (TECH FIG 3).
Remove the diseased fascia and adherent overlying skin as one component.
Close the zigzag Bruner incision and cover the skin defect with full-thickness skin graft from the volar wrist.
TECH FIG 3 • In a patient with recurrent Dupuytren disease with two pretendinous cords in the palm in line with the small and ring fingers causing severe metacarpophalangeal and proximal interphalangeal flexion contracture of the small finger, dermofasciectomy was done for the small finger and partial fasciectomy through a zigzag Brunner incision was done for the ring finger. Correction of the contractures was achieved. Skin shortage in the small finger was covered with a full-thickness skin graft from the volar wrist.
EXTENSIVE FASCIECTOMY
Make either a transverse incision in the middle of the palm or a U-shaped incision in the distal palm (TECH FIG 4A).
The incision has two limbs extending proximally on the ulnar and radial aspect of the digits, forming a broad proximally based skin flap. These can be continued if necessary to the digits with zigzag Brunner incisions.
Undermine the proximal skin flap and distal skin margin by separating the skin from the extensive diseased palmar fascial complex. Retract the flap proximally to expose the deeper structures (TECH FIG 4B).
Carry the dissection proximally and distally to expose the majority of the palmar fascia. A transition between normal and diseased fascia may not be identified. Leave behind any normal-appearing fascial tissue and excise the entire diseased pretendinous cords and adjacent thick nodular structures (TECH FIG 4C).
TECH FIG 4 • A. A U-shaped incision is planned in a patient with diffuse Dupuytren palmar fascial disease with nodular thickening in the entire palm. B. The diseased fascia is exposed after reflection of the proximally based skin flap. C. The excised specimen includes a pretendinous cord from the ring finger and diseased transverse ligament of the palmar aponeurosis. D. The surgical wound after skin closure.
Keep the neurovascular structures in sight and protected all the time.
The TLPA is usually involved, forming a transverse cord that extends from the ulnar to the radial aspect of the palm.
This should be removed with the diseased tissue, along with any natatory cords.
Divide all the septa of Legueu and Juvara to remove most of the diseased fascial carpet.
If these septa are diseased, they will form vertical cords that should be incorporated in the mass of excised tissue.
Release the tourniquet and achieve adequate hemostasis.
Close the wound if possible (TECH FIG 4D), leaving a Penrose drain; it is removed the second postoperative day.
If skin shortage is present, perform full-thickness skin grafting.
Alternatively, the wound can be left open as in the open palm method.
POSTOPERATIVE CARE
Open Palm Fasciectomy
The surgical wound is covered with sterile nonadhesive gauze, which can be changed daily. By 4 weeks no dressings should be necessary.
Forty-eight to 72 hours after surgery the patient begins active range of motion every 2 to 3 hours but maintains nocturnal extension splint immobilization.
Whirlpool therapy can be used early in the postoperative period if unwarranted or excessive bleeding occurred.
Wound healing takes place within 6 to 8 weeks, depending on the extent of the incision.
Partial Fasciectomy and Dermofasciectomy
Range-of-motion exercises are encouraged out of the splint after 1 week. The sutures are removed and splint use is discontinued 2 weeks after surgery in uncomplicated cases.
Formal hand therapy is used after surgery for extensive disease, especially if residual flexion deformity is present. Range of motion alternating with extension splinting is emphasized.
COMPLICATIONS
Complications related to patient physiology include postoperative stiffness, chronic regional pain syndromes, recurrence, loss of digital flexion, and reflex symptomatic dystrophy. The surgeon has little influence in preventing these complications.
Early postoperative complications
Hematoma is prevented by tourniquet deflation and adequate hemostasis before wound closure. Deflating the tourniquet and assessing the skin vascularity before closure to ensure adequate circulation is the best way to prevent skin necrosis.
Closure under tension should be avoided and consideration should be given to grafting or the open palm method if a primary closure is too tight.
Skin necrosis develops after excessive thinning of skin flaps and tight skin closure. Small areas of skin necrosis may be allowed to heal by secondary intention, but large areas of necrotic tissue should be excised, and skin graft or flap coverage is done.
Reflex sympathetic dystrophy, also referred to as a “flare” reaction, may occur after surgery. The patient presents with swelling, hyperemia, dysesthesias, and pain out of proportion to that expected. Direct trauma to the nerve and excessive dissection or stretch of the nerves are thought to be predisposing factors. A simultaneous carpal tunnel release with DD surgery, especially in women, is a predisposing factor. Atraumatic technique and gentle handling of nerves and tissues during surgery should minimize the risk of this complication. If no cause can be identified, the treatment is therapy for pain control. In recalcitrant cases a series of stellate sympathetic ganglion blocks can be helpful.
Late postoperative complications
Inclusion cysts can occur near the scar due to dermal tissue entrapment in the subcutaneous space. This can be prevented by careful attention to skin approximation during wound closure. The risk of hypertrophic scar formation is lessened by careful attention to placement of the skin incisions.
OUTCOMES
The recurrence rate varies between 2% and 60%, with an average of 33%. This may be a true recurrence (recurrent disease at the operated site) or disease extension (disease outside the area of prior surgery). Recurrence is more common in patients with PIP joint involvement, disease in the small finger, more than one digit affected, a longer time since surgery, and a secondary fasciectomy.
Roush and Stern17 reported that the postoperative total range of motion of recurrent DD was better after fasciectomy and flap converge compared to skin grafting or arthrodesis.
DD has intrigued basic scientists and clinicians for centuries. Both ancient6 and current publications5,18 underscore the interest in and the advances toward understanding the pathophysiology of this disease and improving its treatment.
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