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Overview
• Who is Dupuytren?• Definition of Dupuytren disease• Anatomy of the bands and cords• Aetiology and pathopysiology• Recurrence• Clinical assessment • Treatment options
Definition
Dupuytren’s disease is an abnormal thickening of the fascial tissue resulting in digital flexion contractures.
Cell Responsible - Myofibroblast
Fascias
Fascias- Thenar aponeurosis- Ulnar aponeurosis- Palmar aponeurosis- Palmodigital fascia (entraps digital nerve)- Digital fascia
Anatomy
• Superficial transverse ligament is not involved in the disease process
• Natatory ligament causes web space contractures. • In the index finger, Natatory ligament becomes the
distal Commisural ligament and causes contracture between the index finger & thumb.
Anatomy
• Cleland's ligament is not involved in Dupuytren's.• Grayson's ligament contributes to the spiral cord.• The spiral cord pushes the NVB toward the skin &
midline of the finger.
Myofibroblast
• Responsible for contracture • Metaplasia of fibroblast into myofibroblast• Features of smooth muscle cell and fibroblast• Contains actin microfilaments
Associated conditions
1. Epilepsy (42%) 2. Alcohol-induced liver disease 3. Diabetes mellitus 4. COAD5. Hypertension6. IHD
Influencing factors
• Genetics • Trauma• Ischaemia• Alcohol• Phenobarbitone• MMPs and TIMPs• Reduced apoptosis• Free radicals• Interleukin 1
Genetics
• Common among Caucasian (Scottish)– Curse of Mac Crimmons
• Rare in Africans and Middle Eastern descent• Male predominance
Trauma
• Micro ruptures in palmar fascia triggers IL-1• Vasomotor disturbance following swelling in hand
causing secondary Ischaemia
IschaemiaIschaemia
Adenosine Triphosphate Xanthine dehydrogenase(ATP)
Hypoxanthine Xanthine Oxidase
Xanthine &
Uric Acid
OxidationFree Radicals
Ischaemia
• Increase in free radicals• Decrease in antioxidant enzyme activity• Microangiopathy with narrow vessels are found in
dupuytren tissue
Alcohol
• Conversion of Xanthine dehydrogenase to Xanthine oxidase
Increases in free radicals
• Increase in Lysophospatidic acid (LPA)Increases intracellular calcium aiding contracture
Phenobarbitone
• Increase in Lysophospatidic acid (LPA)Increases intracellular calcium aiding contracture
MMPs and TIMPs
• Normal levels of MMPs• Increased levels of TIMPs-1 • Abnormally low MMP : TIMPs ratio
– External fixator to improve contraction prior to surgery is said to increase the level of MMPs
Free radicals
• Fibroblast proliferation6 fold increase in cords40 fold increase in nodule
• Increased production of IL-1• Indirect increase in collagen III
Collagen
• Normal palmar fasciaPredominantly type I collagenLesser extent type III collagen
• Dupuytren fasciaIncreased ratio of type III to type I collagen
IL-1
• Fibroblast proliferation• Stimulates platelets and macrophages to produce
various growth factors (TGF beta)• Reduces apoptosis• Stimulates langerhans cells of the epidermis
Extrinsic pathway: Migration to dermo-epidermal junction – initiates events – contractures
Pathogenesis
Mechanisms
Intrinsic ExtrinsicTGF beta induces Langerhans
cells the differentiation pathwayof fibroblasts into
myofibroblasts
Final contraction
Myosin triggered by LPA
Contraction of Intracellular actin microfilaments
Dupuytren contracture
Stages
Proliferativelarge myofibroblastsvery vascular
InvolutionDense network of myofibroblastsIncreased ratio of type III to type I collagen
ResidualMyofibroblasts disappearPredominantly fibrocytes
Recurrence/Aggressive
1. Young 2. Male 3. Family history 4. Bilateral 5. Fibromatosis elsewhere 6. Garrod's knuckle pads
Summary
• Associated conditions• Various pathways• Role of Free radicals, Interleukin etc• Collagen I replaced by collagen III• Intrinsic and extrinsic theories • Contracture formation• Stages