Summary

Dupuytren's Disease is a benign, progressive fibroproliferative disorder of the palmar fascia. It initially presents as palmar nodules (myofibroblasts) which coalesce into cords, causing fixed flexion contractures of the fingers (Ring > Little). It is strongly genetic, nicknamed "Viking Disease". The threshold for intervention is a positive Hueston's Table Top Test (inability to place the palm flat). Treatment ranges from minimally invasive Needle Aponeurotomy (NA) (high recurrence, low risk) to Limited Fasciectomy (low recurrence, higher risk). The most critical anatomical danger is the Spiral Cord, which displaces the neurovascular bundle centrally and superficially, putting the digital nerve at risk during surgery. [1,2,3]

Key Facts

• Viking Disease: Highest prevalence in Northern Europeans (Scandinavia/Scotland).
• Diathesis: "Dupuytren's Diathesis" refers to aggressive disease: Young onset (<50), Bilateral, Positive Family History, and Ectopic disease (Garrod's Pads, Ledderhose, Peyronie's).
• Pathology: Transformation of fibroblasts to Myofibroblasts (Types III Collagen). Similar to wound healing distinct contraction mechanism.
• The Anatomy: The disease affects the fascia (Pretendinous bands, Spiral bands), NOT the tendons. The tendons are normal.

Clinical Pearls

"Table Top Test": Ask the patient to put their hand flat on the table. If they can't, it is time to discuss surgery. This implies MCP contracture >30 degrees.

"Painless": Dupuytren's is almost always painless. If a patient has a tender lump in the palm, suspect Trigger Finger or a Ganglion first.

"The Spiral Cord Trap": A spiral cord winds around the neurovascular bundle. As it contracts, it pulls the nerve towards the midline and towards the skin. The nerve is NOT where it should be. This is why revision surgery has a 10x risk of nerve injury.

                 DUPUYTREN'S DISEASE
                          ↓
              IS THERE A CONTRACTURE?
              (Positive Table Top Test)
              ┌───────────┴─────────────┐
             NO                        YES
        (Nodules Only)             (Functional Loss)
              ↓                         ↓
         OBSERVE               PATIENT SUITABLE FOR
         (Reassure)            AGGRESSIVE SURGERY?
                             ┌──────────┴──────────┐
                            NO                    YES
                      (Elderly/Low Demand)    (Young/Active)
                             ↓                     ↓
                    NEEDLE APONEUROTOMY       FASCIECTOMY
                    (Percutaneous Release)     (Open Surgery)

1. Needle Aponeurotomy (NA) / Fasciotomy

• Technique: Using a hypodermic needle to act as a scalpel, percutaneously sawing through the cord.
• Pros: Local anaesthetic, Office procedure, Quick recovery (days).
• Cons: High Recurrence (50% at 3 years). Nerve injury risk.
• Indication: Elderly, MCP contracture (nerves safe), patient willing to have repeat procedures.

2. Collagenase Injection (Xiaflex) - Withdrawn in EU/UK

• Mechanism: Bacterial enzyme (Clostridium hystolyticum) dissolves collagen.
• Status: Withdrawn from European market for commercial reasons (2020), but clinically effective. Still used in USA.
• Outcome: Similar to needle aponeurotomy. Risk of tendon rupture.

3. Limited Fasciectomy (The Gold Standard)

• Technique: Open Zig-Zag incision (Bruner). Excision of the diseased fascia. Z-plasty closure to lengthen skin.
• Pros: Lower Recurrence (15% at 5 years). Complete correction.
• Cons: Major surgery. Recovery 6 weeks. Risks (Nerve injury, CRPS, Haematoma).

4. Dermofasciectomy

• Technique: Excision of fascia AND overlying skin. Defect covered with Full Thickness Skin Graft (FTSG).
• Indication: Recurrent disease and Diathesis.
• Rationale: The "Firebreak" theory. Fibromatosis does not recur under a skin graft.

Needle vs Open (Van Rijssen et al. 2012)

• RCT: NA vs Fasciectomy.
• Result: NA had faster recovery and fewer complications, but significantly higher recurrence at 5 years (85% vs 21%).
• Conclusion: NA is good for "quick fix", Fasciectomy is "definitive".

The "Diathesis" (Hueston)

• Factors predicting recurrence:
  1. Bilateral disease.
  2. Age < 50.
  3. Family History.
  4. Ectopic deposits.
• If all present, recurrence is virtually 100%.

What is it?

It is a genetic condition where the layer of tissue under your palm skin thickens and shrinks. It forms tight cords that pull your fingers down so they can't straighten. It is nicknamed "Viking Disease" because it runs in Northern European families.

Do I need surgery?

Not necessarily. If you can still place your hand flat on a table, we leave it alone. If it stops you putting your hand in your pocket or poking your eye, we fix it.

What are the options?

• The Needle: We numb the hand and use a needle to snap the cord. It's quick, no stitches, but it usually grows back in 2-3 years.
• ** The Operation**: We cut the hand open and remove the tissue. It is a bigger deal (6 weeks recovery, splint), but it lasts much longer (10+ years).

Risks

Nerves run right next to the cords. There is a small risk of numbness. Also, the disease is in your DNA, so it can come back even after surgery.

Q1: What is the Spiral Cord? A: It is formed by the coalescence of the Spiral Band, the Lateral Digital Sheet, Grayson's Ligament, and the Pretendinous Band. It is clinically critical because it spirals around the neurovascular bundle, displacing it superficially and centrally, putting it at high risk during surgery.

Q2: Which ligament is spared in Dupuytren's? A: Cleland's Ligament. It is deep to the neurovascular bundle and does not become diseased. It is a useful landmark: everything dorsal to Cleland's is safe; everything volar is disease.

Q3: Name the features of Dupuytren's Diathesis. A: 1. Young age of onset (<50). 2. Bilateral disease. 3. Positive Family History. 4. Ectopic disease (Garrod's pads, Ledderhose, Peyronie's). Presence predicts high recurrence.

Q4: Why use a Skin Graft (Dermofasciectomy)? A: Known as the "Firebreak" theory (Hueston). Myofibroblasts require the dermis-fascia interaction to signals proliferation. Replacing the dermis with a full-thickness graft breaks this recurrence cycle. It is used for recurrent disease or aggressive diathesis.

(End of Topic)