Definition
Dupuytren disease is a fibroproliferative disorder of the palmar and digital fascia that can form nodules and cords, leading to progressive finger flexion contracture.
Associations
Risk is influenced by genetics and is associated with factors including:
- increasing age
- male sex
- family history
- diabetes
- smoking and alcohol exposure
Ectopic fibromatosis such as knuckle pads or plantar fibromatosis may indicate a stronger Dupuytren phenotype.
Associations include:
- family history
- male sex
- increasing age
- ectopic fibromatosis in some patients
Diabetes and other associations may coexist, but causal relationships vary.
Anatomy
Normal fascial bands can become pathological cords. A spiral cord can displace the digital neurovascular bundle and therefore increases operative hazard.
Assessment
Record:
- digits involved
- MCP and PIP contracture separately
- skin involvement
- tabletop function
- neurovascular status
- previous treatment and recurrence
PIP contracture is generally more difficult to correct fully than isolated MCP disease.
Indications for treatment
Treat functional contracture rather than the presence of a nodule alone. Progression, tabletop difficulty and PIP involvement influence timing.
Treatment options
Needle fasciotomy
- minimally invasive
- rapid recovery
- higher recurrence than excisional surgery
Enzymatic cord disruption
Availability varies by region. It can correct selected palpable cords but has local adverse effects and recurrence.
Limited fasciectomy
Removes diseased fascia while preserving skin when possible. It gives more durable correction but carries wound, nerve and vascular risks.
Dermofasciectomy
Used selectively for aggressive recurrent disease or severe skin involvement, with skin grafting.
Complications
- digital nerve or artery injury
- skin loss
- haematoma/infection
- stiffness
- complex regional pain syndrome
- recurrence or extension of disease
No procedure cures the biological tendency to Dupuytren disease.
- nerve injury
- artery injury
- skin loss
- stiffness
- CRPS
- infection
- recurrence
- incomplete correction, especially at PIP
Pathology
Dupuytren disease is a fibroproliferative disorder of the palmar fascia producing nodules and cords that can cause progressive flexion contracture.
It is not a flexor-tendon disorder.
Commonly involved structures include pretendinous cords in the palm and digital cords, which can affect the MCP and PIP joints differently.
Clinical assessment
Record:
- involved rays
- MCP contracture
- PIP contracture
- skin involvement
- nodules/cords
- previous procedures
- neurovascular status
The tabletop test is a useful functional screening sign.
PIP contractures are generally harder to correct and more prone to residual deformity than isolated MCP contractures.
Treatment threshold
Treatment is usually based on function and contracture rather than the mere presence of nodules.
Options include:
- needle fasciotomy
- enzymatic cord disruption where available
- limited fasciectomy
- dermofasciectomy in selected recurrent/aggressive disease
Each has different trade-offs between invasiveness, recovery, correction and recurrence.
Surgical anatomy
Digital cords can displace neurovascular bundles from their expected position. Careful identification is essential, especially in recurrent disease where normal planes are distorted.
Recurrence
Recurrence or extension of disease is common over time. Patients should understand that surgery treats contracture but does not eliminate the underlying biological tendency.
FRCS synthesis
A good answer distinguishes disease from contracture. Treat when contracture impairs function, choose the least burdensome effective technique for the pattern, and counsel explicitly about recurrence.