Definition Dupuytrens


Palmar Fibromatosis 




AD with variable penetration




Murrell's Theory of Pathogenesis


1. Microvascular ischaemia


2. Leads to conversion of 

- ATP to Hypoxanthine

- Endothelial Xanthine Hydrogenase to Xanthine Oxidase


3. Xanthine Oxidase converts Hypoxanthine to Uric Acid

- gives off OH-


4 OH- releases Free Radicals 

- stimulate fibroblast proliferation & increased Type III Collagen


5  Fibroblasts strangle microvessels

- Vicious Cycle  


Luck's three stages of Dupuytren's contracture 


1st stage (proliferative) stage 

- increased cellularity

- number of large myofibroblasts


2nd (involutional) stage 

- dense myofibroblast network aligned to long axis of collagen bundles

- the ratio of Type III collagen to Type I collagen is inc


3rd (residual) stage 

- myofibroblasts disappear 

- fibrocytes are dominant cell type

- dense collagen cord remains




Cell of origin for the nodular myofibroblast is unknown 

- fibroblast / smooth muscle cell / pericyte

- Contractile cell

- nodules composed of myofibroblasts 

- No myofibroblasts in cords


Dupuytren's diathesis 


Aggressive early-onset form of the disease which involves the multiple areas

- usually have family history

- disease recurs rapidly following treatment


Feet (Ledderhose, 1897)

Penis (Peyronie) 

Garrod knuckle pads on dorsum PIPJs




Chronic alcoholism 

- ? metabolic effect on fat and prostaglandin metabolism


Diabetes mellitus 

- may be related to the diabetic microangiopathy



- likely effect of antiepileptic drugs on collagen metabolism




Chronic pulmonary disease


Occupational hand trauma 

- controversial 

- probably only aggravation due to traumatizing an early nodule




Age 50-70

Male 7:1



- especially celtics / vikings heritage

- rare in blacks & asians




A.  Involved anatomy


1.  Pre-tendinous Bands

- part of the palmar aponeurosis in palm

- common site of disease

- palpable nodule is pathognomonic of Dupuytren's


2.  Spiral Band

- continuation of pre-tendinous band into finger

- spirals deep to NV bundle then becomes superficial to bundle


3.  Natatory Ligament

- pass between the web spaces

- frequently diseased and prevents abduction


4.  Lateral Digital Sheet

- condensation of superficial fascia on either side of the finger

- receives fibres from the natatory ligament, spiral band, Grayson's and Cleland's ligaments


5.  Grayson's Ligaments

- hold skin during flexion and extension

- pass from fibrous tendon sheath to the lateral digital sheet

- volar to the NV bundle

- almost always involved in Dupuytren's


B.  Not involved anatomy


Skoog's fibres 

- transverse palmar fibres 

- run from flexor sheath to flexor sheath at the level of the A1 pulley

- the nerve is always deep to the fibres

- part of palmar aponeurosis

- deep to pre-tendinous band

- don't become diseased


Cleland's Ligaments

- hold skin during flexion and extension

- firm fascial structures 

- pass from the side of the phalanges to the skin

- dorsal to the neurovascular bundle

- involved in Dupuytren's only through mingling with the lateral digital sheet


MEM: Dave Christie Goes Volar

(Dorsal Cleland's, Grayson's Volar)




LF / RF most commonly affected

MF / IF are sometimes affected

1st web sometimes affected




5 Major Pathological cords


1.  Pretendinous cord


In palm / other 4 in finger

- diseased pretendinous band

- causes MCPJ deformity


2.  Central cord 


Diseased central fibrofatty tissue

- large nodule often present in cord just proximal to PIPJ

- causes PIPJ deformity


3.  Spiral cord 


Pathological spiral band

- usually connects to the P2 (bone and tendon sheath)

- displaces neurovascular bundle volarly


Difficult to predict presence

- associated with more severe contractures


4. Lateral Cord 


Diseased lateral digital sheath

- intimately adherent to skin (sharp dissection required)

- contributes to DIPJ +/- PIPJ


5. Natatory Cord 


Diseased Natatory ligament

- causes web contracture


3 Minor Cords


1.  Retrovascular Cord 


Involves longitudinal fibers dorsal to the bundle

- commonly seen in combination with other cords

- causes DIPJ extension with lateral cord


2.  Abductor Digiti Minimi Cord 


Cord arises from abductor digiti minimi

- from MT junction 

- to ulnar side of the base of P2

- commonly adheres to the lateral skin


3.  Intercommissural Cords / 1st Web 


Pathological changes in 

- pre-tendinous band (radial longitudinal fiber)

- superficial transverse fibers of the palm (proximal transverse commissural ligament)

- the first web natatory ligaments (Grapow's ligament)




1.  PIPJ Contracture 


4 components

- Central cord 

- Spiral cord 

- Lateral cord 

- Retrovascular cord


Correction sequence

- resection pathological cords

- capsulotomy, release check rein ligaments

- release of accessory collateral ligaments performed

- release of volar plate 


2.  MCPJ Contracture


Always correctable by removal of central band

- Flexion deformity does not lead to collateral shortening 


3.  DIPJ Hyperextension

Occurs in advanced disease

- contracture of retro-vascular + lateral cord




Usually mildly painful nodules to begin

- palm of RF and LF rays

- very short lived


Severe night pain

- suspect fibrosarcoma


Progressive contracture of MCP, then PIPJ

- nodule over PIPJ warning of impending PIPJ contracture


Difficulty putting hands in pockets

- difficult gripping

- poke themselves in the eye



- foot, penis




Nodules / dimples / pits

- palm, fingers





- DIPJ extension

- web space contractures / natatory cords


PIPJ Contracture

- Examine PIPJ with MCPJ flexed

- eliminate effect of cord

- establish if any joint contracture



- feet, Garrod's pads


Hueston Table Top Test

- Royal Melbourne hospital

- palm down on table

- positive if can slide pen under

- MCPJ contracture 30-40o