Dupuytren’s

Contracture

Mr E Mughal
Birmingham Orthopaedic Training
Programme
December 2002
Historical References
1614 Felix Platter of Basel - describes case of
master mason with an irresistible drawing
into the palm of the ring & little fingers and a
ridging of the palmar skin.
1777 Anatomist, Henry Cline Senior (1750 -
1826), the year of Dupuytren's birth. He writes:
The contractions of the fingers which so frequently
happens in laborious people, arises from a thickening
and shortening of the fascia in the palm of the hand,
without any alteration in the muscles and tendons.
Baron Guillaume Dupuytren 1777 -
1835

The beast at the Seine

The brigand of the Hôtel-Dieu
The miser who would give the king one
million francs
First among surgeons, Last among Men
The Napoleon of surgery

He performed his first palmar fasciotomy

on a coachman at the Hotel Dieu in 1831.
Incidence
25% of males over 65yrs.

Associated with:

• Anglo-Saxons
• Family history - autosomal dominant; 68% prevalence
in first-degree relatives
• Epileptics (42%)
• Alcohol-induced liver disease
• Diabetes mellitus
• COAD
• Hypertension
• IHD
Histopathology

Luck (1959) classification of 3 stages

Proliferative
Involutional Proliferative
Residual Large
myofibroblasts
Nodule, focus of proliferating fibroblasts, as the
initial lesion in the proliferativeVascular
stage. He wrote:
"in this local fibroplasia, the fibroblasts do notEC
Minimal align
Matrix
themselves with lines of stress and have, in fact, no
purposeful arrangement"
Histopathology

Involutional
Cells begin aligning
themselves with major
lines of stress
Dense myofibroblast
network
Increase Type III
collagen
Histopathology

Residual Phase
Relatively acellular cords
Densely packed and aligned collagen
fibres
Cells appear as fibrocytes
Initiation and Propagation

Murrell et al. (1989)

Hypertrophic, swollen endothelial cells
and occluded lumina - relative ischaemia
Formation of oxygen-free radicals -
increase myofibroblast proliferation.
Initiation and Propagation (Lappi 1992)
Ischaemic
vascular disease, Release of
Microhemorrhages platelets and
liver pathology,
trauma inflammatory
cells
Oxygen-free
radicals
PDGF &
TGF-beta
released
abundant collagen - Fibroblasts
more hypovascular and proliferate &
more prone to hypoxia initiates collagen
and microhaemorrhages production
Anatomy of the Pathology

Nodules / Pits
MCP contracture
Anatomy of the Pathology

NORMAL DUPUYTREN’S

STRUCTURES 1-
GRAYSON’S 4 SHORTEN
AND FORM
SPIRAL CORD –
LATERAL NVB
DIGITAL DISPLACED TO
SHEET MIDLINE

SPIRAL
BAND

CENTRAL
Anatomy of the Pathology

NORMAL DUPUYTREN’S

STRUCTURES 1-
GRAYSON’S 4 SHORTEN
AND FORM
SPIRAL CORD –
LATERAL NVB
DIGITAL DISPLACED TO
SHEET MIDLINE & PIP
CONTRACTURE
SPIRAL
BAND

CENTRAL
Clinical History
2. Dominance
Fingers get in the way with :-
3. Family history
washing face
4. Rate of progression
combing hair
5. Diabetes
putting hand in pocket
6. Epilepsy
putting hand in glove
7. Alcohol
racquet sports & golf
8. Foot involvement
9. Smoking
10. Trauma
Examination

• Sex
• Sites of nodules & cords
• MCP angle, PIPJ angle
• Knuckle pad
• Sensation
• Risk of RSD
• Table top test of Hueston
• Differential Diagnosis
Similar fibromatosis lesions found
with Dupuytren's: 
• Garrods knuckle pads
• Ledderhose Disease (plantar fibro.) - 5%
• Peyronie's disease (penis) - 3%

Dupuytren's diathesis  (Hueston

1985, McFarlane 1990)
- more prone to recurrence & aggressive dis.
• young
• male
• family history
• bilateral
• fibromatosis elsewhere 
•Garrod's knuckle pads
STAGING - Woodruff, 1998:

Stage Description Management

1 Early palmar disease with Leave alone

no contracture

2 One finger involved, with Surgery

only MCPJ contracture
3 One finger - MCPJ + PIPJ Surgery not easy

4 stage 3 + > one finger Surgery prolonged &

involved only partly succesful

5 Finger-in-palm deformity consider amputation

Indications for Surgery
Surgery indicated when patient is inconvenienced
or incapacitated by the contracture.
MCP > 30 degrees / Early PIP involvement

Counsel the patient

Painful scar
Does not prevent others lesions occurring / Recurrence
Neurovascular injury
Stiffness, CRPS
Post-operative regimen
Aims of Surgery
2. Excise the diseased fascia
3. Release digital contractures
4. Retain full flexion of the digits
5. Preserve neurovascular structures
Incisions (transverse midpalm – McCash / Bruner zig-
zag / Longlitudinal & z-plasties
Surgery - Fasciotomy
Simple division of Dupuytren's band with Beaver
blade
Bryan 1988 - 55% correction maintained at 5 years
(MCPJ)
Less invasive / Quicker recovery
Recurrence more likely / Higher risk NV injury
Indications
• Discrete pretendinous cord with mobile skin
• Affecting MCPJ
• Elderly, moribund pt
• 1st stage procedure for severe disease
Surgery - Segmental Aponeurectomy  

Create a permanent discontinuity in the retracted

aponeurotic band without wide dissection of the
fascia
The retracted band from which tension has been
eliminated will disappear or at least cease to act as a
contracture (Moermans et al., 1984; Moermans, 1990,
1991).
Extended to Dupuytren's disease (Watson, 1984;
Gonzales, 1971, 1985; McGregor, 1985, Moermans et
al., 1996).
Small curved skin incisions about 1.5 cm. long
are made directly over the contracted band
Partial Selective Fasciectomy (Skoog) 
Postoperative Care 
Release tourniquet & achieve haemostasis
Moulded nonadherent compressive dressing
Concept of tubular haematoma
Wrist in extension & fingers comfortable
Regular dressings

Hand Therapy
Up to 3 months
Gosset 1985, 50% operation result depends on
active postop hand therapy programme
Results and Complications

Ischaemic digit
Digital nerve injury
Haematoma !
Skin necrosis
Scar contracture
Stiffness / RSD (4%)
Recurrence – regional fasciectomy
40-50%, only 15% require further
surgery
Dermofasciectomy (Hueston)   

Piulachs and Mir Y Mir 1952

Gordon 1957
Hueston 1962 in recurrent Dupuytren's
disease
Indications
- Dupuytren's diathesis & recurrence
- Severe primary disease
Problems  

Extensive dissection can lead to more

complications - haematomas or RSD
Often partial graft necrosis
After-care difficult - regular dressings and the
prolonged splinting
Skin grafts offer less mechanical resistance than
the normal palmar skin.
External Fixator (Dr Messina & Dr
Messina 1986, 1991)   
Gentle continuous passive traction applied for 2-4 wks to
reduce contracture prior to surgical release
Change property of collagen fibres – weakening –
allowing to stretch

Amputation   
Finger-in-palm deformity with macerated skin   
Neuromas, biomechanical