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Dr Akasha Amber,
Pgr Plastic & Reconstructive Surgery
Unit,BVH,BWP
History
• Baron Guillaume Dupuytren
▫ Described it in a lecture in 1831
• Felix Plater 1st described it in 1614
• Henry Cl...
Dupuytren’s disease
• Progressive, overarching, superficial
fibromatoses
▫ (peyronie’s disease, ledderhose’s disease)
• No...
Epidemiology
• Most prevalent in Northern Europe
• Historically, Nordic, Caucasian, Anglo-Saxon &
Viking disease
• Male:fe...
Associated factors
• Alcohol abuse
• Hepatic disease
• HIV
• Malignancy(paraneoplastic syndrome)
• DM
• Repetitive trauma
...
Palmar fascia
• Firm, flexible framework covering soft tissue
• Tethering skin to underlying structures
• 2 layers
▫ Deep ...
Pretendinous bands
Natatory ligament
Proximal transverse palmar
ligament
Proximal commissural ligament
Distal commissural
...
Palmar apponuerosis
• 3 types of fibres
▫ Longitudinal,transverse,vertical
• Longitudinal:
▫ From PL to distal palmar crea...
Digital fascia
• Complex palmar-digital fascia junction
• Deep & intermediate fibres bifurcate
▫ Contribute to digital ret...
Digital fascia Grayson’s ligament
Natatory ligament
Pretendinous band
Transverse fibers of
palmar aponeurosis
Spiral band
...
1st web space
• Longitudinal fibres
▫ Extend radially, insert into skin at MCPJ level
▫ Insert into I/M septum between add...
Basic science
• Fibro-proliferative disease
• Alterations in:
▫ β-catenin pathway
▫ Fibroblast gene expression
▫ Extracell...
pathology
• 3 phases
• Proliferative phase
▫ Nodule formation in palmar fascia
▫ Increased fibrinolytic activity and myofi...
Disease process
• Mild thickening to severe contractures
• Diseased bands named as cords
▫ Palmar,digital,palmodigital,hyp...
diseased
structure
Anatomic origin Clinical
significance
Palmar cords Pretendinous
cord
Pretendinous band MCP joint flexio...
diseased
structure
Anatomic origin Clinical significance
Digital cords Central cord Pretendinous cord
(digital extension)
...
Grading
• Grade 1
▫ Thickened nodule and band in the palmar
apponeurosis; may have associated skin
abnormalities
• Grade 2...
Staging
Differential diagnosis
• camptodactyly
• traumatic scar contracture
• burn scar contracture
• Volkmann’s ischemic contract...
diagnosis
• Clinical
• No radiologic technique
Management plan
• Thorough history
▫ impairment in hand shaking, fitting of gloves,difficulty
placing the affected hand in...
Treatment options
• Conservative/observation
• Steroid injection
• Collagenase injection
• Needle apponeurotomy
• Surgical...
No contracture,no pain
• Only skin pitting,hand mass(patient ‘ll say) or
tightness in fingers or palm
• Explain,reassure a...
Painful palmar nodules
• Early active disease
• Do not excise or flaring up
• Steroid injection
Dorsal dupuytren’s disease
• At dorsal knuckle pads/garrod’s pads at PIPJs
• Conservative or excise
Contracted fingers
• Interventions:
• Needle apponeurotomy
• Collagenases
• Limited fasciectomies
• Dermatofasciectomy/ski...
Needle apponeurotomy
• Percutaneous needling into cord followed by
manipulation
▫ 25 G needles
• Cord weakening
• Cord rup...
collagenases
• Collagenase enzyme(clostridium histolyticum)
▫ Xiaflex at a dose of 0.58 mg per injection
• CRUCIAL: patien...
skin
Subcutaneous tissue
Dupuytren’s cord
Deep fat
Flexor tendon
Metacarpal
Limited fasciectomy
• Standard
▫ surgical excision of diseased tissue/Cords
• The more the excision ,the lower the recurre...
Dermatofasciectomy/skin grafting
• For extensive/recurrent/sin involving disease
• All scarred fascia &overlying skin remo...
Soft tissue distraction
• E.g digit widget, a skeletally anchored hardware
▫ Under local block
• Stretches soft tissues
▫ ...
delimmas
• Pale finger
▫ Ait 20 minutes,warm saline,vasodilators,injury
assesment
• PIPJ intrinsic flexion
▫ Controversial...
Other techniques
• Skeletal traction
• Wedge osteotomy
▫ Dorsal wedge of proximal phalanx
• Total volar tenoarthrolysis
▫ ...
Newer technique
• Radiotherapy
• 5-Fluorouracil
• Imiquimod
• Botulinum toxin
• Ilomastat
• Hyperbaric oxygen
thanks
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
Dupuytren's disease
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Dupuytren's disease

  1. 1. Dr Akasha Amber, Pgr Plastic & Reconstructive Surgery Unit,BVH,BWP
  2. 2. History • Baron Guillaume Dupuytren ▫ Described it in a lecture in 1831 • Felix Plater 1st described it in 1614 • Henry Cline ▫ described pathological anatomy and features of this disease
  3. 3. Dupuytren’s disease • Progressive, overarching, superficial fibromatoses ▫ (peyronie’s disease, ledderhose’s disease) • Nodular thickening & contracture • Palmar and digital fascia • MCP & PIP joint level
  4. 4. Epidemiology • Most prevalent in Northern Europe • Historically, Nordic, Caucasian, Anglo-Saxon & Viking disease • Male:female is 6:1 • Male in 50s, women in 60s • Genetic disorder, Autosomal dominant inheritance
  5. 5. Associated factors • Alcohol abuse • Hepatic disease • HIV • Malignancy(paraneoplastic syndrome) • DM • Repetitive trauma • Smoking • COPD • epilepsy
  6. 6. Palmar fascia • Firm, flexible framework covering soft tissue • Tethering skin to underlying structures • 2 layers ▫ Deep fascia ▫ Superficial fascia/palmar apponeurosis • Palmar apponeurosis ▫ triangular fascia with apex in continuity with palmaris longus
  7. 7. Pretendinous bands Natatory ligament Proximal transverse palmar ligament Proximal commissural ligament Distal commissural ligament of 1st webspace(lig of grapow) Palmar cutan.br of median nerve Palmaris longus tendon Triangular space
  8. 8. Palmar apponuerosis • 3 types of fibres ▫ Longitudinal,transverse,vertical • Longitudinal: ▫ From PL to distal palmar crease,attachments to retrovascular fascial structures,deep dermis, distally bifurcating into slips attaching on sides of MCP joint • Transverse: ▫ Proximal transverse band,at level of distal palmar crease, deep to longitudinal pretendinous band,radially prox.commissural ligament  No affected by DD ▫ Distal transverse band(natatory ligament),ulnarly splitting & enclosing NVB & ADM, radially distal commissural ligament of 1st web space(lig of GRAPOW)  Affected by DD • Vertical(fibres of Legueu and juvara) ▫ Attaching deep dermal surface to deep palmar fascia ▫ Series of 8 Vertical septa, splitting longitudinal compartments
  9. 9. Digital fascia • Complex palmar-digital fascia junction • Deep & intermediate fibres bifurcate ▫ Contribute to digital retrovascular bands • Invested by dorsal and volar fascial sheets ▫ Superfiscial to ext. & flex. mechanisms • Lateral structures investing NVB ▫ Cleland’s ligament  V shaped dorsal fibre bundles from prox & distal of PIPJ to lateral digit.sheets (not involved in disease) ▫ Grayson’s ligament  From flex.tendon sheath to skin volar to NVB ▫ Transverse retinacular ligament  From volar capsule of PIPJ dorsally into extensor mechanism • Spiral bands from pretendinous bands; to lateral digital sheets
  10. 10. Digital fascia Grayson’s ligament Natatory ligament Pretendinous band Transverse fibers of palmar aponeurosis Spiral band Lateral digital sheet Cleland’s ligament
  11. 11. 1st web space • Longitudinal fibres ▫ Extend radially, insert into skin at MCPJ level ▫ Insert into I/M septum between adductor pollices & 1st D/I muscle ▫ Into flexor tendon sheath of index finger • Transverse fibres ▫ Natatory ligament continues as ligament of Grapow ▫ Proximal transverse fibres as proximal commissural ligament
  12. 12. Basic science • Fibro-proliferative disease • Alterations in: ▫ β-catenin pathway ▫ Fibroblast gene expression ▫ Extracellular matrix genes down-regulation ▫ Deposition of collagen type 1 & 3, extracellular matrix ▫ Myofibroblast hyperactivity ▫ Role of androgenic hormonal receptor
  13. 13. pathology • 3 phases • Proliferative phase ▫ Nodule formation in palmar fascia ▫ Increased fibrinolytic activity and myofibroblast formation • Involutional phase ▫ Increased nodular thickening ▫ Joint contracture formation ▫ Type 3 collagen deposition • Residual phase ▫ Type 3 replaced by type 1 collagen ▫ Myofibroblasts disappear
  14. 14. Disease process • Mild thickening to severe contractures • Diseased bands named as cords ▫ Palmar,digital,palmodigital,hypothenar and 1st web space cords
  15. 15. diseased structure Anatomic origin Clinical significance Palmar cords Pretendinous cord Pretendinous band MCP joint flexion contracture Vertical cord Vertical fibers of McGrouther or septa of Legueu and Juvara Causes painful triggering Palmodigital cords Spiral cord Pretendinous band, spiral band, lateral digital sheet, Grayson’s ligament Displaces the Neurovascular bundle medially and superficially (spiral nerve) Natatory cord Natatory ligament (distal fibers) Webspace adduction contracture
  16. 16. diseased structure Anatomic origin Clinical significance Digital cords Central cord Pretendinous cord (digital extension) PIP joint flexion contracture Retrovascular cord Retrovascular band of thomine PIP and DIP joint flexion contracture; prevents full correction of PIP joint contracture Lateral cord Lateral digital sheet (often closely associated with pretendinous and natatory cord) PIP and DIP joint flexion contracture; Displaces neurovascular bundle medially Abductor digiti minimi cord Abductor digiti minimi tendon PIP joint flexion contracture Thumb and first webspace cords Proximal commissural cord Proximal commissural ligament First-web adduction contracture Distal commissural cord Distal commissural ligament First-web adduction contracture Thumb pretendinous cord Pretendinous band MCP joint flexion contracture
  17. 17. Grading • Grade 1 ▫ Thickened nodule and band in the palmar apponeurosis; may have associated skin abnormalities • Grade 2 ▫ Development of pretendinous and digital cords with limitation of finger extension • Grade 3 ▫ Presence of flexion contracture
  18. 18. Staging
  19. 19. Differential diagnosis • camptodactyly • traumatic scar contracture • burn scar contracture • Volkmann’s ischemic contracture • intrinsic joint ankylosis • locked trigger finger • spastic digital contracture • Callosity • foreign body • desmoid fibroma • nodular fasciitis • fibrosarcoma
  20. 20. diagnosis • Clinical • No radiologic technique
  21. 21. Management plan • Thorough history ▫ impairment in hand shaking, fitting of gloves,difficulty placing the affected hand in a pocket, and impairment in grasping large objects. • Physical examination ▫ Functional limitations ▫ Degree of contracture of each finger ▫ Quality of overlying skin ▫ Hand examination  compressive neuropathies ▫ Other fibromatosis in body • Initial consultation ▫ About disease origin,course,syptomatic treatment,disease recurrence & progression
  22. 22. Treatment options • Conservative/observation • Steroid injection • Collagenase injection • Needle apponeurotomy • Surgical fasciectomies • Skeletal traction
  23. 23. No contracture,no pain • Only skin pitting,hand mass(patient ‘ll say) or tightness in fingers or palm • Explain,reassure and instructions when to return for intervention
  24. 24. Painful palmar nodules • Early active disease • Do not excise or flaring up • Steroid injection
  25. 25. Dorsal dupuytren’s disease • At dorsal knuckle pads/garrod’s pads at PIPJs • Conservative or excise
  26. 26. Contracted fingers • Interventions: • Needle apponeurotomy • Collagenases • Limited fasciectomies • Dermatofasciectomy/skin grafting • Soft tissue distraction
  27. 27. Needle apponeurotomy • Percutaneous needling into cord followed by manipulation ▫ 25 G needles • Cord weakening • Cord rupturing by finger manipulation • Digital nerve neuropraxia • Skin tear • High recurrence • Disease not removed • Less invasive,no incision • Effective for MCPJ cords
  28. 28. collagenases • Collagenase enzyme(clostridium histolyticum) ▫ Xiaflex at a dose of 0.58 mg per injection • CRUCIAL: patient counselling for swelling & bruising(indicates effect of enzyme) • hand prep, 3 sites injection within cord • Return for manipulation and cord release ▫ 24 hours or 1 week later ▫ Under LA • Splinting of hand at night for 3 months • Effective for MCPJ • Minimally invasive • Low recurrence rate • Swelling,bruising,skin tear • Deep injection ruptures FLEXOR TENDONS • Two visits,one cord at a time • costly
  29. 29. skin Subcutaneous tissue Dupuytren’s cord Deep fat Flexor tendon Metacarpal
  30. 30. Limited fasciectomy • Standard ▫ surgical excision of diseased tissue/Cords • The more the excision ,the lower the recurrence • Strict post-operative care ▫ splinting till suture removal then night splining • Complications of surgery: ▫ Infection,delayed wound healing,nerve injury,post surgical scar contractures • Incision ▫ Brunners-type incision ▫ Straight line over cord with multiple Z-plasties
  31. 31. Dermatofasciectomy/skin grafting • For extensive/recurrent/sin involving disease • All scarred fascia &overlying skin removed • Resurfaced with skin graft • Potential risk of graft loss • Long rehabilitation
  32. 32. Soft tissue distraction • E.g digit widget, a skeletally anchored hardware ▫ Under local block • Stretches soft tissues ▫ Collateral ligaments,NVB • Straightens the contracture ▫ Usually in 5 weeks • 2nd stage removal of dupuytren’s disease ▫ Limited or dertmatofasciectomies • Postoperative rehabilitation • Effective fore severe PIPJ contractures • Two stages, tolerate the device for several weeks
  33. 33. delimmas • Pale finger ▫ Ait 20 minutes,warm saline,vasodilators,injury assesment • PIPJ intrinsic flexion ▫ Controversial to release joint ▫ Releasing checkrein and accessory collateral ligament • Simultaneous release of dupuytren’s contracture and carpel tunnel syndrome ▫ Risk of Post–op pain(unproven)
  34. 34. Other techniques • Skeletal traction • Wedge osteotomy ▫ Dorsal wedge of proximal phalanx • Total volar tenoarthrolysis ▫ Sectioning volar plate and flexors(FDS,FDP) • PIP arthrodesis • Amputation
  35. 35. Newer technique • Radiotherapy • 5-Fluorouracil • Imiquimod • Botulinum toxin • Ilomastat • Hyperbaric oxygen
  36. 36. thanks
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    Nov. 28, 2019
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    Nov. 2, 2018
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    Sep. 29, 2018

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