Pitfalls

• Procedures performed by "limited exposure" still require adequate visualization of the neurovascular structures that may be displaced from their normal location.

• Neurovascular structures may be displaced superficially and toward the midline of the digit by the spiral cord and should not be assumed to be in their anatomic position. Generally, tracing the neurovascular structures is easier in a proximal to distal direction starting just distal to the transverse carpal ligament.

• Neurovascular structures are displaced more toward the midline and more superficial with increasing PIP contracture.

Differential Diagnosis

Dupuytren's contracture Joint flexion contracture Scar contracture Flexor tendon bowstring Tendon adhesions Tumor (i.e., fibrosarcoma)

Bowstring Tendon
Figure 27—1. Preoperative clinical photo.

Diagnosis

Dupuytrens Contracture

Dupuytren's disease has been attributed to genetic lines of Viking heritage and northern European lineage with an autosomal-dominant pattern of inheritance. The condition presents most frequently in males and after the age of 40. Clinical features include painless palmar pitting, cords, and nodules frequently in line with the small and ring finger. Many structures, described as "ligaments" and "bands" in their normal state, are referred to as "cords" in the diseased state (Fig. 27—2). The spiral cord is a continuum of the diseased spiral band, lateral digital sheet, and Grayson's ligament. The spiral cord is pulled to the midline with contracture, causing the neurovascular bundle to wrap around the straightening and tightening cord. The natatory cord can be palpated in the web space, and its contracture deviates the digit from the midline at the MP joint. See the suggested readings, later, for more comprehensive descriptions of the pathoanatomy. Disease progression generally leads to characteristic flexion deformities of the MP and the PIP joint. Associated findings include dorsal knuckle pads (Garrod's nodules), thickening of plantar tissue in the foot (Lederhose's disease), and penile fascia (Peyronie's disease).

Indications for surgical correction of Dupuytren's contracture depend greatly on the impact of the deformity on the patient's ability to perform activities of daily living and the ability and willingness of the patient to participate in the postoperative rehabilitation. Hard-and-fast, objective surgical indications are difficult to define. The "tabletop test" provides the earliest sign of significant flexion contracture, although this test alone is not always an indication for surgery. The test is positive when the patient cannot fully flatten his or her hand against a table surface. Generally, flexion deformities of the MP joints are better tolerated by the patient and are relatively easier to correct, as MP flexion is a relatively "safe" position that maintains

Natatory Ligament
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