Clinical Example: Dupuytren Distal Interphalangeal Joint Needle Fasciotomy
| Dupuytren
contracture usually involves the metacarpophalangeal and
proximal interphalangeal joints, but occasionally
affects the distal interphalangeal joints. This is
usually accompanied by proximal interphalangeal joint
involvement. This is almost always a lateral rather than
a central cord, and may present as a spiral cord, the
neurovascular bundle superficial just proximal to the
distal interphalangeal joint. The functional impact of this is that it contributes to the fingertip catching on things like a hook. Isolated interphalangeal joint contractures in the context of hyperextensible metacarpophalangeal joints allow patients to defer evaluation until the contracture is severe. The most common method of treating this is with fasciectomy, but needle fasciotomy may be effective. Collagenase has been used for this, but is an off-label application. As with needle release or collagenase treatment of the proximal interphalangeal joint, recurrence is expected: these minimal procedures should be considered a temporizing step with expectations of partial improvement. The following are examples of percutaneous needle fasciotomy for a variety of contractures involving the distal interphalangeal joint. Portals proximal and/or distal to the distal interphalangeal joint flexion creases are used, some bilaterally. These are presented to illustrate the diversity of even this subset of Dupuytren disease. None had prior treatment. Marking legend: . = Needle portals o = depot steroid injection x = portal planned, but not used. The technique is essentially the same as that for isolated PIP joint release, as shown here. |
| Click on each image for a larger picture |
| Case
1. 40 year old right handed man with
several year history of
minimal bilateral Dupuytren disease. The left small finger has reached a point of functional impairment from combined proximal and distal interphalangeal joint contractures. |
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| Needle Portals |
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| End of Procedure |
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| Case
2. 26 year old left handed man with a
five year
history of left small finger Dupuytren disease involving the proximal and distal interphalangeal joints. |
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| End of Procedure |
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| Case
3. 60 year old left handed man with a 3
year history
of left small Dupuytren disease. |
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| End of Procedure |
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| Partial
recurrence three years later. This was treated with a repeat release. |
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| End of Redo Procedure. |
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| Case
4. 57 year old right handed man with a
22 year
history of Dupuytren disease affecting his left small finger. |
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| Planning
of portals (dots) and nodule steroid injection sites (circles). Radiograph of affected finger, 90° contracture. |
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| End
of Procedure. Minimal improvement, but the joint felt rubbery to passive stretch, and so he was treated with a night time static extension splint. He had progressive improvement. |
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| 18
months later, improvement persists. |
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| Despite
this, recurrence is likely due to early age of onset and ectopic disease: unusual Ledderhose with toe nodules (left); unusual knuckle pads at the DIP joints (right) |
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| Case
5. This 50 year old gentleman noticed
Dupuytren disease of his left hand
five years ago. He now has bilateral contractures, worse on the right. |
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| End of Procedure |
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| Case
6. This 71 year old man has a 15 year
history of right small finger Dupuytren disease,
which had
become noticeably more contracted in the last six months. |
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| End of Procedure |
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| Recurrence
four years later treated with repeat release. |
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| End of redo procedure |
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| Six
weeks after second procedure. |
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| Case
7. This 63 year old right handed man
has an eight
year history of Dupuytren disease of the right small finger. |
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| End of Procedure. |
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| Case
8. This 85 year old right handed woman
has a 13 year
history of bilateral disease, worse on the right. |
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| End of Procedure. |
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| Case
9. This 67 year old right handed man
has a 20 year
history of Dupuytren disease of his left hand. |
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| End of Procedure. |
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| Case
10. This 68 year old left handed man has
a 20 year
history of Dupuytren disease of his left hand. |
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| End of Procedure. |
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| Case
11. This 71 year old right handed man
has a 10 year
history of right small finger disease. |
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| End of Procedure. |
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| Continued
improvement, now five months postop. |
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| Case
12. This 72 year old man had a one year
history of right ring finger Dupuytren
contracture, progressing mostly in the last six months. He had left small finger Dupuytren surgery 16 years ago, and had unknown right palm surgery over 20 years ago. |
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| End of Procedure. |
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| Case
13. This 81 year old man has had
bilateral disease
for 3 years, stable for the last two years. |
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| Planned
portals. |
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| End of Procedure. |
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| Case
14. This 79 year old right handed man
has a five year
history of bilateral Dupuytren disease, worse on the right hand. |
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| Planned portals. |
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| End of Procedure. |
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| Case
15. This 72 year old right handed man
has a 3 year history of progressive
left small finger Dupuytren disease. His finger catches on everything. |
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| End of Procedure. |
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| Case
16. This 62 year lod right handed man
has had
bilateral disease for 5 years, worse on the left. |
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| End of Procedure. |
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