Dupuytren Disease, Contracture, and Soft-Tissue Coverage
Fascial anatomy and the reconstructive ladder
Dupuytren disease. A fibroproliferative disorder of the palmar fascia producing nodules and cords. The pretendinous cord contracts the MCP joint; the spiral cord (pretendinous band, lateral digital sheet, Grayson's ligament) contracts the PIP joint and displaces the digital nerve centrally - the classic operative trap. Natatory cords contract the web spaces. The Hueston tabletop test is positive when the palm cannot lie flat. Diathesis (young age, bilateral disease, family history, ectopic disease such as knuckle pads, plantar fibromatosis, or Peyronie disease) predicts aggressive recurrence. Options: observation for mild disease; percutaneous needle aponeurotomy for a single cord; collagenase injection with manipulation at 24–48 hours; limited fasciectomy for extensive disease; dermofasciectomy with grafting for recurrent disease in a young patient.
Contracture and coverage. Intrinsic-plus deformity (MCP extension, PIP flexion) reflects intrinsic tightness. Burn scar contracture is released along relaxed skin tension lines and grafted. Coverage ladder: secondary intention, skin graft, local flap (Moberg for thumb tip up to about 2 cm, cross-finger, thenar, V-Y advancement), regional flap (radial forearm, posterior interosseous, groin), free flap (ALT, lateral arm) for large defects.
Traps: dividing a spiral cord without protecting the displaced digital nerve; assuming collagenase prevents recurrence; and using a Moberg flap for a defect larger than the thumb pulp.
Rule of thumb: recurrence is highest after needle aponeurotomy and lowest after dermofasciectomy - counsel accordingly.