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Category Archives: Plastic surgery

Dupuytrens disease

Dupuytrens disease is one of those diseases which present to our Plastic Surgery OPD frequently.Most of the patients come to us, when they are unable to work.So it is the functional limitation due to this disease that forces the person to consult expert help.Let us see what this disease is about.

What is dupuytrens disease?

Dupuytren’s disease is a progressive disease of the palmar and digital fascial structures characterized by nodular thickening and subsequent contracture. Deformity of the hand occurs primarily at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint level.This results in functional limitations to the patient.

Dupuytrens disease is closely related to Peyronie’s disease (penile fibromatosis) and Ledderhose’s disease (plantar fibromatosis).It is  most prevalent in populations with a strong northern European ancestry. Men are six times more likely to develop Dupuytren’s disease than are women.It usually begins in 5th decade in men and 6th decade in women.It has an autosomal dominant inheritance pattern.

Associations

Repetetive trauma,chronic obstructive pulmonary disease, human immunodeficiency virus, malignancy (paraneoplastic manifestation), and epilepsy have been associated with Dupuytrens contracture.

Palmar fascia and its role in Dupuytrens disease

Dupuytren’s disease is ultimately manifest as the transformation of the normal palmar and digital fascial structures to thickened diseased cords through the deposition of type I and type III collagen and the contractile forces generated by myofibroblasts.

The palmar fascia provides a flexible yet firm framework for the soft tissues of the palm, tethering the skin to the underlying musculoskeletal structures.

Layers of Palmar fascia

The palmar fascia consists of two distinct layers: the deep fascia and the superficial fascia or palmar aponeurosis. The deep fascia covers the interosseous muscles and is not involved in Dupuytren’s disease. The superficial fascia, in contrast, is affected by the pathologic progression of Dupuytren’s disease.

Pathogenesis of Dupuytrens disease

The pathogenesis of Dupuytren’s contracture in pathologic terms is divided into proliferative, involutional, and residual phases.

Proliferative phase

The proliferative phase is characterized by nodule formation within the palmar fascia and biochemically by increased fibrinolytic activity.

Involutional phase

Marked nodular thickening and signs of early joint contracture characterize the involutional phase. Throughout the involutional phase, type III collagen is synthesized and the myofibroblasts reorient along the lines of tension within the palm.

Residual phase

Type III collagen deposition continues and is gradually replaced with type I collagen throughout the residual phase.Myofibroblasts disappear leaving predominantly Type I and Type III collagen.

Signs in Dupuytrens disease

1.  Hugh Johnson sign- Widening of the skin crease in Dupuytrens disease

2. Short–Watson sign- A soft palpable fullness immediately adjacent to the cord at the level of the MCP joint may indicate displacement of the neurovascular bundle by a pathologic spiral cord

 

 Treatment

a)Non Operative

Extension splinting to prevent prevent contracture.

Ultrasound therapy has been reported to soften palmar nodules but has not been effective in the treatment of cords or contracture.

b)Injection treatment

Steroids have demonstrated a restrictive effect on the formation of fibrous tissue and scar.Steroids are effective in treating palmar nodule.

Enzymatic fasciotomy-Injection in enzymatic fasciotomy is performed with 0.58 mg clostridial collagenase diluted in 0.25 mL (MCP joint) or 0.20 mL (PIP joint) of sterile diluent. The cord is
located by manual palpation and injection is performed at three points along the length of the cord via a single puncture with a 25-gauge needle.

Injection is done at 1 month intervals, injection is followed by manual manipulation and night splinting.

c) Surgical Treatment of Dupuytrens contracture

Surgical treatment of Dupuytren’s disease consists of both fasciotomy and fasciectomy. Fasciotomy involves division of the diseased cords without excision and may be performed
via an open technique or percutaneously. Fasciectomy involves excision of the diseased cords.

Surgical treatment of dupuytrens in itself is a vast topic, and will be delt with in the next post.

Skin Grafting-Types of skin grafts

Anatomy of the human skin with English languag...

Anatomy of the human skin with English language labels. Arabic language description translated by: Tarawneh (Photo credit: Wikipedia)

Split thickness skin grafts

 

Also known as thiersch graft,split-thickness grafts consist of epidermis and a variable thickness of dermis. Thinner grafts (<0.016 in.) have a higher rate of engraftment, whereas thicker grafts, with a greater amount of dermis, are more durable and aesthetically acceptable. Common donor sites are the thigh, buttock, and scalp.

 

Full thickness skin grafts

 

Also known as Wolfe graft ,full-thickness grafts include epidermis and a full layer of dermis. Common donor sites include groin and postauricular and supraclavicular sites, but the hypothenar eminence and instep of the foot can also be used. The donor site is usually closed primarily. These grafts are generally used in areas for which a high priority is placed on the aesthetic result (e.g., face and hand).

 

Thinner grafts have greater secondary contraction and do not grow commensurate with the individual. They have fewer adnexal cells and therefore have variable pigment, less hair, and less sebum, with a proclivity toward dryness and contractures. Full-thickness grafts, with more dermis and the requisite adnexal structures, exhibit less contraction and better cosmesis.

 

Graft meshing

 

Grafts can be meshed in expansion ratios from 1.5:1 to 6:1. Meshing a graft allows coverage for a wider area using the same-size donor site and decreases the risk of serous fluid accumulating under the graft without a method of egress. The interstices are covered within 1 week by advancing keratinocytes. However, because the entire area is not covered by dermis, meshed grafts are less durable, and the meshing pattern remains after healing, making them inappropriate for aesthetically important areas, such as the face.
Graft healing.

 

Factors affecting graft take

 

Initial metabolism is supported by imbibition or diffusion of nutrients from the wound bed. Revascularization occurs between days 3 and 5 by ingrowth of recipient vessels into the graft (inosculation).

 

Therefore, for a graft to take, the bed must be well vascularized and free of infection, and the site must be immobilized for a minimum of 3 to 5 days. Prevention of shear forces is particularly important during this period of inosculation.

 

Although bare bone and tendon do not engraft, periosteum and peritenon can support skin grafts, especially if they are first left to form a layer of granulation tissue. Graft failures are most often the result of hematoma, seroma, or shear force prohibiting diffusion and vascular ingrowth.

 

Source:Washington manual of surgery

Classification of nerve injuries

Sunderlanda Seddonb Structure injured Prognosis
First degree Neurapraxia Schwann cell (demyelination) Complete recovery within 12 wk
Second degree Axonotmesis Axon (wallerian degeneration) Complete recovery regeneration 1 mm/day
Third degree Endoneurium Incomplete recovery
Fourth degree Perineurium No recovery
Fifth degree Neurotmesis Epineurium No recovery
Sixth degree Mixed injury, neuroma, incontinuity Unpredictable recovery

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