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Clinical case: Dupuytren's contracture: want to learn more about it?

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Clinical case: Dupuytren's contracture

In this article, we describe a case of a woman suffering from Dupuytren’s disease. We will follow her journey from admission and history all the way to prognosis and evolution. We will also look at the classical sign of this condition called Dupuytren's contracture, together with possible treatment options and relevant anatomical considerations.

Case key facts
Treatment options Percutaneous Needle Aponeurotomy, enzyme injections, surgical removal of the palmar fascia
Flexor digitorum superficialis

Origin: medial epicondyle of the humerus, radial tuberosity

Insertion: bases of middle phalanges of the four fingers

Innervation: median nerve

Action: flexion of the middle phalanges

Flexor digitorum profundus

Origin: anterior and medial surfaces of the ulna, interosseous membrane, deep fascia of the forearm

Insertion: bases of distal phalanges of the four fingers

Innervation: ulnar and median nerves

Action: flexion of the middle phalanges and wrist

Trigger finger A snap or audible pop caused by the movement of a nodule within a palmar digital sheath during finger flexion. The nodule appears due to irritation and inflammation of a flexor tendon.

After reviewing this case you should be able to describe the following:

  • The overall goal of treatments for Dupuytren’s disease. What is meant by Percutaneous Needle Aponeurotomy (PNA). Other treatments for the condition.
  • The anatomical/functional differences between the flexor digitorum superficialis and profundus.
  • The synovial and fibrous digital sheaths of the hand. What is meant by trigger finger.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden. 

It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Case description

History and clinical presentation

Figure 1. Photograph of dissection of cadaver forearm showing flexor digitorum profundus (FDP) deep to flexor digitorum superficialis (FDS; reflected).

The patient is a retired, right-handed, 73-year-old woman with a history of smoking. The patient had previously undergone bilateral aponeurotomy (surgical release) for digitopalmar Dupuytren's disease. At her two-year follow-up exam, her left hand showed excellent results, but her right hand showed a recurrence involving the fourth digit near the metacarophalangeal (MCP) joint. A Percutaneous Needle Aponeurotomy (PNA) was performed in the digital area.

Three weeks later, the patient showed a marked flexion deficiency in the distal interphalangeal (DIP) joint, which occurred without making an effort; the patient did not undergo rehabilitation or wear a splint.

Figure 2. Cadaveric image showing the flexor digitorum superficialis (FDS) and profundus (FDP) tendons in digital sheaths of the fingers. The FDS tendon is splitting and inserting on middle phalanx. The FDS and FDP tendons are entering the fibrous digital sheath.

 

Imaging

An MRI showed a rupture of the flexor digitorum profundus (FDP) tendon at the first phalanx of the fourth digit with retraction of the proximal stump into the palm (Figures 2&3). This required outpatient surgical intervention.

Figure 3. Axial T2 MRI of the right hand showing absence of the FDP tendon to the fourth digit (highlighted with green). FPL, flexor pollicis longus.

Management and evolution

Under loupe magnification, the proximal stump of the profundus tendon was located in the palm and resected. In a later surgery, tenodesis (suture of a tendon to bone) of the distal stump was performed at the entrance to the fibrous sheath and at the palmar plate of the distal interphalangeal joint (DIP) at 10° of flexion. A dorsal splint that provided support to the DIP was worn five weeks. Six months after this surgery, the patient was satisfied but had a fixed flexure of the proximal interphalangeal (PIP) joint of 20° of her fourth finger.

Anatomical and medical considerations

Palmar aponeurosis

The palmar aponeurosis (palmar fascia) is a thick layer of fascia that invests the muscles of the palm, and is divided into central, lateral, and medial portions (Figure 4).

The central portion occupies the middle of the palm, is triangular in shape, and is thick. The proximal apex of the palmar aponeurosis is continuous with the lower margin of the transverse carpal ligament (flexor retinaculum), and is the insertion of the expanded tendon of the palmaris longus. The distal base of the palmar aponeurosis divides into four slips, one for each finger. Each slip gives rise to superficial fibers to the skin and finger; the deeper part of each slip subdivides into two processes, which are attached to the fibrous digital sheaths of the flexor tendons. This arrangement results in channels anterior to the heads of the metacarpal bones for the flexor tendons. The spaces among the four slips allow for passage of the digital vessels and nerves, and the tendons of the lumbrical muscles (first lumbrical is labeled in Figure 4).

Figure 4. Cadaveric image of the hand showing the main component of the palmar aponeurosis.

Dupuytren's disease

Dupuytren’s disease is a fibrosing condition that causes slowly progressive thickening and shortening of the palmar fascia, resulting in debilitating digital contractures, especially of the MCP or PIP joints (Figure 5). The condition usually begins with small hard subcutaneous nodules (Figure 5C) just under the skin of the palm. Dupuytren’s disease progresses until the fingers cannot be extended (Figure 5). Whereas typically disease is not painful, some aching or itching may be present. The 4th digit is usually the first one affected followed by the 5th and 3rd digits. The contractures interfere with most manual activities.

Figure 5. Photographs of the hands of patients with Dupuytren’s disease (not from patient in this case). A. Patient with typical contracture of ring finger. B. Patient with contracture of ring and little fingers. C. Nodule (and associated pit) on hand of patient. D. Patient with visible fibrotic cord. All photographs courtesy of Dupuytren’s Contracture Institute.

Explanations to objectives

Objectives

  • The overall goal of treatments for Dupuytren’s disease. What is meant by Percutaneous Needle Aponeurotomy (PNA). Other treatments for the condition.
  • The anatomical/functional differences between the flexor digitorum superficialis and profundus.
  • The synovial and fibrous digital sheaths of the hand. What is meant by trigger finger.

Treatments for Dupuytren's disease and percutaneous needle aponeurotomy

The goal of treatments for Dupuytren’s disease is to lessen the contractures and any discomfort caused by the condition. The treatment involves removing or breaking apart the cords of fibrous material that characterize the condition. Percutaneous Needle Aponeurotomy (PNA; needling) is a technique that uses a needle, inserted through the skin, to puncture and disrupt the cords of tissue that are causing the deformity. Contractures often recur but the procedure can be repeated. The primary advantages of PNA are that there is no incision, it can be done on multiple fingers simultaneously, and usually very little physical therapy is needed afterward. The main disadvantage is that there is a risk of nerve or tendon damage (as in this case).

Dupuytren’s disease can also be treated by enzyme injections that soften and weaken the fibrosis, which allows for manipulation that may be able to disrupt the cords and allow the fingers to extend. A third option for patients with advanced disease is to have the palmar fascia surgically removed. The primary advantage to surgery is that it results in a more complete and longer-lasting treatment than that provided by the two prior approaches (although in the case of this patient, the condition did recur in one hand after surgery). The main disadvantages are that physical therapy is typically needed after surgery, and recovery can be prolonged.

Differences between the flexor digitorum superficialis and profundus muscles

The FDS has two heads of origin - the humeroulnar (medial epicondyle of humerus) and radial heads, and from these heads four long tendons arise near the wrist and traverse the carpal tunnel. The tendons traverse across the palm and run along the ventral aspects of the digital rays to attach to the anterior margins on the bases of the middle phalanges of the four fingers. These tendons split (Camper's Chiasm) as they terminate to allow for passage of the FDP tendons (Figure 2). The FDS is innervated by the median nerve. The primary function of the FDS is flexion of the middle phalanges of the fingers at the PIP joints; however this muscle will also act to flex the MCP and wrist joints.

Figure 6. Flexor digitorum superficialis - anterior view

The FDP originates in the upper 3/4 of the anterior and medial surfaces of the ulna, interosseous membrane and deep fascia of the forearm. The muscle splits into four tendons for the fingers, passes through the carpal tunnel and palm to insert into the palmar base of the distal phalanx of each of the four fingers. The FDP lies deep to the superficialis, but attaches more distally by passing through the superficialis tendons. The medial part of the muscle (which flexes the 4th and 5th digits) is innervated by the ulnar nerve (C8, T1) whereas the lateral aspect (which flexes the 2nd and 3rd digit) is innervated by the median nerve, specifically its anterior interosseous branch (C8, T1). FDP is a flexor of both IP joints, the MCP, and the wrist joints. The lumbrical muscles of the hand arise from the radial side of each of the FDP tendons. Thus, this flexor muscle acts to assist the lumbrical muscles in their role as extensors of the IP joints. The force generated by the FDP at the more distal joints is controlled by wrist position. Flexion of the wrist causes muscle shortening, reducing the ability to generate tension distally. Extension of the wrist allows for more powerful digital flexion at the distal joints.

Figure 7. Flexor digitorum profundus - anterior view

Synovial and fibrous digital sheaths of the hand

The flexor tendons as they enter the palm are retained in place by fascial retinacula, and are invested by synovial sheaths, which facilitate free movements of the tendons. Three synovial sheaths are located anterior to the wrist:

  1. a common synovial flexor sheath the envelops all of the superficialis and profundus tendons;
  2. a sheath that surrounds the tendon of the flexor pollicis longus; and,
  3. the flexor carpi radialis, which has a has a short sheath.

Untreated infection of the synovial sheaths is liable to impair hand function. The common and pollical sheaths are often referred to clinically as the ulnar and radial bursae, respectively. The sheath that envelopes the FDS and FDP extends distally about midway along the metacarpal bones, where it ends in blind diverticula around the tendons to the index, middle, and ring fingers.

Once the flexor tendons emerge from the common flexor sheath they continue distally without a synovial sheath for a short distance (1 to 3 cm) until they become enveloped by their own tendon sheaths. These synovial tendon sheaths begin at the level of the metacarpal heads and extend to the distal phalanges. Synovial sheaths provide tendons with a large degree of freedom of movement. The fibrous digital sheaths on the palmar surface of the fingers keep the long digital flexor tendons in place during movements of the fingers. The fibrous sheaths are divided into the annular ligaments of the fingers, often referred to as A pulleys and less frequently vaginal ligaments, and the three cruciate pulleys. The annular and cruciate ligaments facilitate the flexor mechanism of the hand and wrist, preventing bowstringing upon contraction of the muscle.

Sometimes one or more of the flexor tendon becomes irritated and inflamed (swells), reducing the space for the tendon to move within its fibrous sheath (tunnel). The swelling may result in the development of a nodule that causes a snap or audible pop as the nodule moves within the sheath when the finger(s) is flexed. This is called trigger finger or stenosing tenosynovitis.

Clinical case: Dupuytren's contracture: want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

Sign up for your free Kenhub account today and join over 1,234,089 successful anatomy students.

“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

Show references

Reference:

  • Otayek S, Pierrart J, Masmejea EH. Dupuytren's disease and needle aponeurotomy: rupture of a deep common flexor tendon: A case report and literature review. Journal of Orthopaedic Case Reports 2016 July-Aug;6(3): 88-90.
  • Modified by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Authors:

  • Joel A. Vilensky 
  • Carlos A. Suárez-Quian
  • Aykut Üren

Layout and review:

  • Abdulmalek Albakkar
  • Dimitrios Mytilinaios  
  • Adrian Rad

Illustrators:

  • Figure 6. Flexor digitorum superficialis (anterior view) - Yousun Koh
  • Figure 7. Flexor digitorum profundus (anterior view) - Yousun Koh
© Unless stated otherwise, all content, including illustrations are exclusive property of Kenhub GmbH, and are protected by German and international copyright laws. All rights reserved.

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