Peter Brenner

Theories concerning etiology and pathogenesis

The search for a link between Dupuytren’s disease and other internal medical disorders aims at finding identical, reproducible pathways consistent with a common etiology. The many possible explanations that have been published in the literature cannot be reproduced here. Therefore, this book focuses on the most popular hypotheses and on those that are particularly controversial at the current time.

Dupuytren’s disease—a historical overview

The clinical details of digitopalmar contractur—enow known as Dupuytren’s disease, and topic of the famous lecture at HOpital-Dieu in Paris on 5 December 1831 by the French anatomist and surgeon Guillaume DUPUYTREN (1777–1835; Fig. 2), had been described in much earlier publications (COOPER, 1824; PAILLARD and MARX, 1831; DuPUYTREN, 1831, 1832, 1834).

Errors, hazards, and complications

Hazards and complications begin with patient selection. Care has to be taken to strictly adhere to indications for and contraindications to fasciectomy.

Symptoms of Dupuytren’s contracture

Funnel shaped disturbances of the skin relief (skin pits) in the vicinity of the proximal or distal creases characterize the early stage of the disease (MAILANDER, BRENNER et al., 1994).

Selection of surgical techniques

Fasciotomy is the simplest procedure. One needs to distinguish between subcutaneous fasciotomy, which is done by palpation only (“blind”), and locoregional fasciotomy, where the skin, subcutis, and the bowstringing cord are divided under vision. This minimal invasive procedure aims to improve hand function by simple division of the cord. It is a palliative procedure, primarily indicated in the elderly whose general condition is poor. It should be used in younger patients whenever a more invasive fasciectomy is not indicated.

Anatomy of the palmar fascia (G. M. Rayan)

Familiarity with the subtle constituents of the complex palmar fascial anatomy of the hand is necessary to understand the convoluted pathologic changes that take place in Dupuytren’s disease and the transformation from a normal to a pathologic anatomy.

Additional measures to improve hand function

Even after prolonged episodes of flexion, full function of the metacarpophalangeal joint can usually be restored. That does not hold true for the proximal interphalangeal joint. Residual contractures of the proximal interphalangeal joints up to 30 degrees do not impair everyday tasks (CROWLEY et al., 1999).

Course of Dupuytren’s contracture

Dupuytren’s disease can either progress slowly, being interrupted by phases of stagnation, or it can cause contracture-induced dislocations of the digital joints within a short time (MILLESI, 1959, 1965; MIKKELSEN, 1977). This is dependent on a person’s individual disposition (STRICKLAND et al., 1990).

Preoperative work up

Detailed documentation of the loco regional status is the essential minimum; this includes measurement of joint movement for all digital joints as per the neutral-zero-method (MP, PIP, and DIP joints), finger spread (distance from the tip of the thumb to the little finger), finger extension deficit (distance from the plane of the dorsum of the hand to the free border of the nail), finger flexion deficit in centimeters (from the plane of the nail to the distal palmar crease), a basic neurological assessment, and data about the peripheral perfusion.

Anesthesia and positioning

DUPYTREN (1831; 1832) presumably used alcohol and opium as anesthetics, a common practice in his day. As he did not use a tourniquet, the patient’s hand was raised above heart level, and the surgeon stood behind the patient. Nowadays, we use brachial plexus block, a tourniquet, and the patient’s upper extremity is positioned on a special arm table. The surgeon sits comfortably next to the arm table and uses surgical loupes (McGROUTHER, 1988; WYLOCK, 1997). The arm is kept in about 90-degree abduction. The tourniquet is inflated to 300 mm Hg, in hypertensive patients it is inflated to 100 mm Hg above the systolic blood pressure.