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Dupuytren’s disease -Quick revision card

progressive , irreversible and often bilateral ,affects the palmar fascia benign nodular proliferative process of palmar aponeurosis connective tissue under the skin of the palm contracts and becomes tough over time type III collagen which is thicker than type I is laid gradually collagen knots and fibres in the palmar fascia are formed 3 recognised stages ( 1 ) proliferative (2 ) involution (3 ) residual fascial bands change into pathological cords -causing deformity eventually thick collagen cords cause flexion deformity of the affected metacarpophalangeal joint ( MPJ ) or proximal interphalangeal joint

 

Risk factors – family history ancestry ( Northern European
descent ) male sex age ( increases with age ) more common in heavy smokers low body weight elevated fasting blood glucose , diabetes epilepsy carpal tunnel syndrome h/o or current manual labor hypercholesterolaemia hand injury

 

What happens also known by other names as Dupuytren’s disease , palmar fibromatosis common fibroproliferative disabling disorder affecting the palmar surface of hands , mostly seen in Caucasians of Northwestern European origin inherited connective tissue disorder ( inheritance may be autosomal dominant but often the aetiology is multifactorial ) prevalence increases with age & men suffer more than women affects typically white middle aged and older men ( rarely seen in Blacks and Asians ) studies have shown a prevalence of up to 30 % in the Norwegian population in the UK it is estimated that it affects about 3 % to 5% of the general population

 

Presentation – pain is usually not a presenting problem most commonly involved finger is the ring finger followed by the little , thumb , middle and index fingers firm bands restrict movements ( tightness ) which interferes with activities of daily living subcutaneous nodules on distal palmar crease indentations or cords that develop under the skin note the extent of the disease , skin involvement and joint contractures contractures start in the palm and extend distally gradually loss of range of movements Hueston’s table top test is inability to place all fingers in a flat position on a tabletop Ectopic manifestation can be seen in plantar fascia ( Ledderhose’s disease ) , Peyronie disease ( Dartos fascia of penis )

 

Differentials – severe trigger finger flexor tendon / sheath tumour ganglion cysts ulnar neuropathy soft tissue tumours

 

Referral impact of the condition on patients life positive table top test MCP contracture > 30 degrees PIP contracture of 15 to 20 degrees Severe thumb contractures which interfere with function Painful nodules Rapid progression over a few months Knuckle pads ( Garrod’s nodes -benign fibrofatty s/c pads located over th PIP jts , often mistaken for arthritis

 

Observation & f/u ( not all cases are progressive ) Steroid inj’s ( may not work for all / recurrence ) physical / occupational therapy

 

Needle aponeurectomy ( break the cords , used for mild cases ) Collagenase injection – dissolves the collagen Fasciectomy- involves surgery , removal of the involved palmar and/ or digital fascia ( can be partial or total ) Surgery complications -include skin necrosis , haematoma , flare reactions , N/V injury , digital ischaemia , swelling , infection

REFERENCES

  1. Dibenedetti, Dana Britt et al. “Prevalence, incidence, and treatments of Dupuytren’s disease in the United States: results from a population-based study.” Hand (New York, N.Y.) vol. 6,2 (2011): 149-58. doi:10.1007/s11552-010-9306-4
  2. Hindocha S, McGrouther DA, Bayat A. Epidemiological evaluation of Dupuytren’s disease incidence and prevalence rates in relation to etiology. Hand (N Y). 2009 Sep;4(3):256-69. doi: 10.1007/s11552-008-9160-9. Epub 2009 Jan 15. PMID: 19145463; PMCID: PMC2724613.
  3. Gudmundsson KG, Arngrímsson R, Sigfússon N, Björnsson A, Jónsson T. Epidemiology of Dupuytren’s disease: clinical, serological, and social assessment. The Reykjavik Study. J Clin Epidemiol. 2000 Mar 1;53(3):291-6 ( Abstract ). doi: 10.1016/s0895-4356(99)00145-6. PMID: 10760640.
  4. Walthall J, Anand P, Rehman UH. Dupuytren Contracture. [Updated 2021 Nov 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526074/
  5. Dupuytren’s disease Dupuytren’s disease | Health topics A to Z | CKS | NICE
  6. Geoghegan JM, Forbes J, Clark DI, Smith C, Hubbard R. Dupuytren’s disease risk factors. J Hand Surg Br. 2004 Oct;29(5):423-6. doi: 10.1016/j.jhsb.2004.06.006. PMID: 15336742. ( Abstract )
  7. *Dupuytrens disease presentation, referral pathways and resource utilisation in Europe: regional analysis of a surgeon survey and patient chart review
  8. Karbowiak MHolme TKhan KMohan ADupuytren’s disease doi:10.1136/bmj.n1308 Dupuytren’s disease | The BMJ
  9. Tamborrini, Giorgio et al. “Knuckle pads – a rare finding.” Journal of ultrasonography vol. 12,51 (2012): 493-8. doi:10.15557/JoU.2012.0037

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