MALLET FINGER____BASEBALL FINGER

MALLET FINGER (BASEBALL FINGER)

A mallet finger occurs when the extensor tendon at the tip of a finger ruptures. The rupture of this tendon can involve the tendon alone, be associated with a small bone fragment or fracture or can be associated with a fracture that requires significant care.

The force applied to the finger can come from something as simple as tucking in a bed sheet or can come from a direct blow to the end of a finger. Mallet finger has also been known as baseball finger.

A mallet finger often begins with pain at the distal joint of the finger.  At times there is an immediate loss of motion while at other times the finger seems to stay straight for a while and only later starts to lose its ability to be extended actively at the tip.  At times there is an injuries are typically closed in that the skin and nail is intact but at times there is an injury to the skin or nail bed as well. In severe cases the injury is associated with an open injury to the joint or bone, a so called open or compound fracture.

In adults the injury can involve the joint surface.  In children it can involves the growth plate or physis.

The diagnosis is often made based upon the type of injury and the appearance of the finger.  The fingertip will droop down and there is a loss of active motion.  Often the finger can be passively pushed up to straighten it but the independent active motion to extend the digit at the tip has been lost

Mallet finger.

X-rays are often taken to further delineate the injury and see how much if any bone, joint or growth plate is involved

Treatment depends largely upon the extent the soft tissue and underlying boney injury.

Tendon rupture without bone injury

Most of these mallet finger injuries can be treated with splinting.  The splint can be applied in a variety of ways depending upon the injury.  Typically the split is left in place full time for six to eight weeks with a time for part time splinting after that depending upon what daily activity is done by the patient with a typical part time period of 3 – 4 weeks.  In some situations pinning of the joint is used rather than a splint

Tendon rupture with a small bone fragment

These injuries typically are treated like non-boney injuries

Types of splints used to treat mallet finger. A, Dorsal aluminum splint. B, Commercial splint.

Reproduced with permission from Culver JE Jr: Office management of athletic injuries of the hand and wrist. Instr Course Lect 1989;38:473-482.

Tendon rupture with a large bone fragment involving the joint.

These injuries may respond to splinting and splinting is often used however a small bump may always be present a t the joint.  At times if the doctor feels that that the bone fragment is large enough and the joint may be unstable surgery may be offered.  During surgery pins or small screws may be used and the joint itself may be pinned to prevent motion during the healing process.

Above: X-rays showing fracture at the insertion of the extensor tendon. In the first image on the left the fragment is displaced.  This will heal with a bump but will be able to be treated with a splint.  IN the image on the right the joint has subluxed.  This will  need to have surgical repair.

In adults with severe open injury more immediate surgery may also be offered

Children

In children the doctor needs to differentiate between these injuries that require reduction or realignment of the bone without surgery and those who may have a portion of the nail bed significantly torn or retained within the fracture site or growth plate.  Often children will not have a tendon injury but a fracture through the physis which appears to be a mallet injury.  X-rays often will reveal this.

Mallet deformity from a fracture across the growth plate in a child is different than the adult fracture or tendon avulsion

Late or Delayed Treatment in adults

Delayed treatment of mallet finger deformity may consist of splinting initially and at times surgical methods are offered to correct chronic deformities and other associated joint and tendon problems that may accompany the chronic situation

Results

Most mallet fingers heal well, although often there is a slight loss of full extension. The slight extension loss typically has no effect on hand of finger function, but if left untreated it can cause other issues to occur in the finger due to tendon imbalance. While treatment of a closed mallet finger is not an acute emergency, the improper, partial or untreated injury can lead to further problems such as a swan neck deformity.

 Swan neck deformity from tendon imbalance and laxity at the proximal joint.

 

Athletics

While there may be special circumstances where a professional athletes plays with a splint in place for mallet finger for the child or recreational athlete, or even most professional or collegiate level athletes this is not typically recommended.

CARPAL BOSS of the HAND and WRiST

Carpal Boss

  

Clinical Characteristics

The dorsal wrist ganglion is most often confused with the carpal boss, so named by the French physician Foille.  The carpal boss is an osteoarthritic spur that develops at the base of the second and/or third carpometacarpal joints. (figure 1) A firm, bony, nonmobile, tender mass is visible and palpable at the base of the carpometacarpal joints, especially 

when the wrist is volar flexed. The lining of the joint thins out and small bone spurs form n the top of the hand leadingto a bone prominence. Tendon irritation can occur and a small cyst or ganglion may form as well.

figure 1 Right hand with carpal boss

Figure 2 Carpal Boss seen on Xray

Radiologically, the mass is best visualized with the hand in 30 to 40 degrees supination and  

 20 to 30 degrees ulnar deviation ("carpal boss view")( figure 2).

The boss is more common in women (2:1), in the right hand (2:1), and between the third and fourth decades.  The mass may be asymptomatic, but the patient may complain of considerable pain and aching.  A small ganglion is associated with  the carpal boss in 30 percent of cases, adding to its confusion with the more common dorsal wrist ganglion. 

Injection to the ganglion or to the cmc joint may  be used to reduce pain and irritation.  This may be combined with splinting and anti inflammatory medication and avoidance of trauma to the back of the hand\

If symptoms persist at times surgery may be offered. (figure 3) Surgery may involve the removal of the prominent bone, the excision of an associated ganglion or cyst and at times involves tenosynovectomy or tenolysis of adjacent affected tendons.  What occurs during surgery may depend upon the preoperative findings as well as the surgical intra operative findings

Figure 3  Surgical Approach to carpal boss excision using a transverse incision

The most common complication is the persistence of a mass because of excision of the ganglion alone or inadequate excision of the osteophytes.  Pain will persist unless all abnormal abutting surfaces have been excised.  Dorsal wrist ganglions can present over the carpometacarpal joints and must be distinguished from the carpal boss with its own associated ganglion.  Avoidance of injury to branches of the radial and ulnar sensory nerves is again stressed.            

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fireworks safety stressed

Fireworks danger stressed

Thursday, July 01, 2004

By NANCY H. GONTER

ngonter@repub.com

NORTHAMPTON - Hand surgeon Jeffrey Wint isn't expecting a quiet Fourth of July weekend.
"Unfortunately, I face the prospect of being called in at any time," said Wint, who hopes to take in a parade and spend some time in his back yard during the holiday.

Wint, other medical professionals, law enforcement and fire officials yesterday held a press conference calling on area residents to "leave fireworks to the professionals." Members of the state police bomb squad exploded illegal fireworks using mannequins to show the damage they can cause.

A surgeon at the Hand Center of Western Massachusetts who works at Baystate Medical Center in Springfield, Wint said he has already seen hand injuries caused by fireworks this season.

In one case, a teenage boy was clenching a firecracker in his hand and it blew up before he threw it. The tip of his index finger had to be amputated. In another case, a 14-year-old boy didn't realize the cherry bomb in his hand was lit. He suffered burns to his palm, deep lacerations and several fractures.

"He has the prospect of months of therapy and rehabilitation in order to regain normal function," Wint said.

Of injuries to the hand and upper extremities, 57 percent are caused by fireworks, Wint said.

Patrick C. Lee, a trauma surgeon at Baystate Medical Center, said burn injuries are tragic for children and their families.

"They are a life-changing event. Burns and their treatment are painful, leave surgical and emotional scars, and most of all they are preventable," Lee said.

State Fire Marshal Stephen D. Coan said many people ask him why children shouldn't play with sparklers.

"I ask them if they would give their children a lighter to play with. Sparklers can burn at 1,800 degrees Fahrenheit, three times the temperature of a lit match, and hot sparkler fires have ignited clothing, burned bare feet, poked eyes out and started tragic holiday fires," Coan said.

Coan noted that all fireworks are illegal in Massachusetts and it is illegal to bring fireworks into the state, even though they are legal in Connecticut and New Hampshire. It is also illegal to purchase fireworks on the Internet or through catalogs and have them delivered to homes in Massachusetts, he said.

"Remember, the use of fireworks by anyone other than a licensed professional is illegal," Coan said.

The press conference featured a table loaded with fireworks in colorful packaging, much of it clearly intended to attract children. The fireworks were seized by law enforcement authorities. Coan noted children 10-14 are at the greatest risk of fireworks injuries.

Fireworks can be deadly. In December 2003, a 45-year-old Gloucester woman died when fireworks ignited her Christmas tree, starting a house fire. In May 1997, a 26-year-old Watertown man was killed when lighting fireworks in a hallway. On July 4, 1993, a 27-year-old Framingham man was killed when his backyard fireworks exploded in his face, according to the state Department of Fire Services.

MORE ON FIREWORKS

Fireworks safety

 

Fireworks Safety Brief
LOSSES
According to the Consumer Product Safety Commission, national losses involving fireworks amount to 3 deaths and 10,527 injuries annually. Hand and finger injuries are the most common and account for 32 percent of all injuries. Head and eye injuries occur with about the same frequency, equaling 19 and 18 percent of total injuries.
BACKGROUND
A review of firework mishaps shows a variety of factors contribute to the typical mishap. Most pre-school age victims are injured by fireworks ignited by someone else, while older children who are injured are usually lighting the fireworks themselves. Children under age five are commonly hurt by rocket-type fireworks; small firecrackers and ground spinners injure the majority of children between the ages of 5 and 14. Most of the injuries associated with large, illegal firecrackers such as M-80's are to older teenagers or adults.

FOR MORE INFORMATION concerning fireworks safety go to these links below.

NFPA--FireworksSafetyTips.pdf
AAOS press release
ASSH fireworks 2006 press release
Press Release Summer 2004
Channel 22 WWLP Springfield , 6/30/04 
Springfield Republican Article 7/1/04
http://www.fireworksafety.com/statelaws/index.html

Flexor Tendon Injuries 

Flexor tendons in the hand and forearm

The muscles that bend (flex) the fingers are called flexor muscles. These flexor muscles move the fingers through cord-like extensions called tendons, which connect the muscles to bone. The flexor muscles start at the elbow and forearm regions, turn into tendons just past the middle of the forearm, and attach to the bones of the fingers (see Figure 1). In the finger, the tendons pass through fibrous rings called pulleys, which guide the tendons and keep them close to the bones, enabling the tendons to move the joints much more effectively.

Deep cuts on the palm side of the wrist, hand, or fingers can injure the flexor tendons and nearby nerves and blood vessels. The injury may appear simple on the outside, but is actually much more complex on the inside. When a tendon is cut, it acts like a rubber band, and its cut ends pull away from each other. A tendon that has not been cut completely through may still allow the fingers to bend, but can cause pain or catching, and may eventually tear all the way through. When tendons are cut completely through, the finger joints cannot bend on their own (see Figure 2).The Hand that has a ruptured or cut flexor tendon will not have a normal pattern or cascade to the finger tips. Observation of the hand will reveal that the finger with a cut or ruptured flexor tendon will "stick out" due to the absence of normal resting tension (see Figure 3)


How are flexor tendon injuries treated?

Tendon Healing

Tendons are made of living cells. If the cut ends of the tendon can be brought back together, healing begins through the cells that are inside of the tendon as well as the tissue outside of the tendon. Because the cut ends of a tendon usually separate after an injury, a cut tendon can not heal without surgery.

Your doctor will advise you on how soon surgery is needed after a flexor tendon is cut. There are many ways to repair a cut tendon, and certain types of cuts need a specific type of repair. In the finger, it is important to preserve certain pulleys, and there is very little space between the tendon and pulley in which to perform a repair. Nearby nerves and blood vessels may need to be repaired as well. After surgery, and depending on the type of cut, the injured area can either be protected from movement or started on a very specific limited-movement program for several weeks (see Figure 4). Your doctor may prescribe hand therapy for you after surgery. If unprotected finger motion begins too soon, the tendon repair is likely to pull apart. After four-to-six weeks, the fingers are allowed to move slowly and without resistance. Healing takes place during the first three months after the repair.

In most cases, full and normal movement of the injured area does not return after surgery. If it is hard to bend the finger using its own muscle power, it could mean that the repaired tendon has pulled apart or is bogged down in scar tissue. Scarring of the tendon repair is a normal part of the healing process. But in some cases, the scarring can make bending and straightening of the finger very difficult. Depending on the injury, your doctor may prescribe therapy to loosen up the scar tissue and prevent it from interfering with the finger’s movement. If therapy fails to improve motion, surgery to release scar tissue around the tendon may be required.

Hand Therapy After Surgery
If a program of controlled, limited motion is selected as therapy for the first several weeks after surgery, it is important to work closely with a hand therapist and your surgeon to understand the therapy and follow set guidelines. The tendon repair might pull apart if your hand is used too soon or if therapy guidelines are not followed. In addition to regaining motion of the finger after a tendon injury, therapy will be helpful in softening scars and building grip strength.


Figure 1: The tendons of the hand run from the flexor muscles in the elbow and forearm to the bones of the fingers.

Figure 2: When flexor tendons are completely cut, the finger cannot be bent.


Figure 3: After a flexor tendon rupture or laceration the affected finger will often stick out and not follow the normal cascade or posture of the resting hand.

Figure 4: After surgery, the area of the injured tendon must be protected from movement.

Portions © 2009 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee
Taken, modiifed and adapted by www.handctr.com from www.assh.org ( ASSH)
Portions © from www.handctr.com
flexor_injuries.pdf

forearm fractures in children

Forearm Fractures in Children

Description

Symptoms

Nonsurgical Treatment

Surgical Treatment

Children love to run, hop, skip, jump and tumble. But if they fall onto an outstretched arm, they could break one or both of the bones in the forearm.
Forearm fractures account for 40 to 50 percent of all childhood fractures. Fractures can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone.

Description

Fractures of both forearm bones.

The bones of the forearm are the radius and the ulna. If you hold your arm naturally by your side, the ulna is the bone closer to you and the radius is farther away. About three out of four forearm fractures in children involve the wrist-end of the radius. A child's bones begin to heal much more quickly than an adult's bones. If you suspect a fracture, you should obtain prompt medical attention for the child so that the bones can be set for proper healing.
Types of fractures include:

• Torus fracture: This is also called a "buckle" fracture. The topmost layer of bone on one side of the bone is compressed, causing the other side to bend away from the growth plate. This is a stable, nondisplaced fracture.
• Metaphyseal fracture: The fracture is across the upper or lower portion of the shaft of the bone and does not affect the growth plate.
• Greenstick fracture: The fracture extends through a portion of the bone, causing it to bend on the other side.
• Galeazzi fracture: The injury affects both bones of the forearm. There is usually a displaced fracture in the radius and a dislocation of the ulna at the wrist, where the radius and ulna come together.
• Monteggia fracture: The injury affects both bones of the forearm. There is usually a fracture in the ulna and the top (head) of the radius is dislocated. This is a very severe injury and requires urgent care.
• Growth plate fracture: Also called a physeal fracture, this fracture occurs at or across the growth plate. Usually these fractures affect the growth plate of the radius near the wrist.

The hand, wrist, arm, and elbow can all be injured during a fall on an outstretched arm. To determine exactly what injuries occurred, the doctor will probably want to see X-rays of the elbow and wrist as well as the forearm. The doctor will also test to make sure that the nerves and circulation in the hand and fingers are not affected.

Top of page

Symptoms

This child's forearm fracture has resulted in a bent appearance of the forearm. It will require a manipulation to restore normal alignment prior to placement in a cast.

(Courtesy of Texas Scottish Rite Hospital for Children)

Symptoms of a forearm fracture include:

• Any type of deformity about the elbow, forearm, or wrist
• Acute pain
• Tenderness
• Swelling
• An inability to rotate or turn the forearm

Treatment depends on the type of fracture and the degree of displacement.

Top of page

Nonsurgical Treatment

Some may simply need the support of a splint or cast until they heal. If the bones do not break through the skin, the physician may be able to push (manipulate) them into proper alignment without surgery.

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Surgical Treatment

Casts support and protect broken bones while they heal.

Surgery to align the bones and secure them in place may be required if:

• The skin is broken.
• The fracture is unstable.
• Bone segments have been displaced.
• The bones cannot be aligned properly through manipulation alone.
• The bones have already begun to heal at an angle or in an improper position.

After the bones are aligned, the physician may use pins, metal implants, or a cast to hold them in place until they have healed.
A stable fracture, such as a buckle fracture, may require three to four weeks in a cast. A more serious injury, such as a Monteggia fracture-dislocation, may need to be immobilized for six to ten weeks.
If the fracture disrupts the growth plate at the end of the bone, the physician will probably want to watch it carefully for several years to ensure that growth proceeds normally.

Top of page

Last reviewed and updated: April 2009

Reviewed by members of POSNA (Pediatric Orthopaedic Society of North America)

AAOS does not review or endorse accuracy or effectiveness of materials, treatments or physicians.


Selected Abstracts

Returned:1 citations and abstracts. Click on down arrow or scroll to see abstracts.

Sundeep Khosla, L. Joseph Melton III, Mark B. Dekutoski, Sara J. Achenbach, Ann L. Oberg, B. Lawrence Riggs

Incidence of Childhood Distal Forearm Fractures Over 30 Years: A Population-Based Study JAMA 290: 1479-1485.  

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Abstract 1 of 1
Incidence of Childhood Distal Forearm Fractures Over 30 Years

A Population-Based Study
Sundeep Khosla, MD; L. Joseph Melton III, MD; Mark B. Dekutoski, MD; Sara J. Achenbach, MS; Ann L. Oberg, PhD; B. Lawrence Riggs, MD
JAMA. 2003;290:1479-1485.
Context  The incidence of distal forearm fractures in childrenpeaks around the time of the pubertal growth spurt, possiblybecause physical activity increases at the time of a transientdeficit in cortical bone mass due to the increased calcium demandduring maximal skeletal growth. Changes in physical activityor diet may therefore influence risk of forearm fracture.
Objective  To determine whether there has been a changein the incidence of distal forearm fractures in children inrecent years.
Design, Setting and Patients  Population-based study amongRochester, Minn, residents younger than 35 years with distalforearm fractures in 1969-1971, 1979-1981, 1989-1991, and 1999-2001.
Main Outcome Measure  Estimated incidence of distal forearmfractures in 4 time periods.
Results  Comparably age- and sex-adjusted annual incidencerates per 100 000 increased from 263.3 (95% confidenceinterval [CI], 231.1-295.4) in 1969-1971 to 322.3 (95% CI, 285.3-359.4)in 1979-1981 and to 399.8 (95% CI, 361.0-438.6) in 1989-1991before leveling off at 372.9 (95% CI, 339.1-406.7) in 1999-2001.Age-adjusted incidence rates per 100 000 were 32% greateramong male residents in 1999-2001 compared with 1969-1971 (409.4[95% CI, 359.9-459.0] vs 309.4 [95% CI, 259.3-359.5]; P = .01)and 56% greater among female residents in the same time periods(334.3 [95% CI, 288.6-380.1] vs 214.6 [95% CI, 174.9-254.4];P<.001). The peak incidence and greatest increase occurredbetween ages 11 and 14 years in boys and 8 and 11 years in girls.
Conclusions  There has been a statistically significantincrease in the incidence of distal forearm fractures in childrenand adolescents, but whether this is due to changing patternsof physical activity, decreased bone acquisition due to poorcalcium intake, or both is unclear at present. Given the largenumber of childhood fractures, however, studies are needed todefine the cause(s) of this increase.

Author Affiliations: Endocrine Research Unit, Division of Endocrinology, Metabolism, and Nutrition, Department of Internal Medicine (Drs Khosla and Riggs), Department of Health Sciences Research (Drs Melton and Oberg and Ms Achenbach), and Department of Orthopedic Surgery (Dr Dekutoski), Mayo Clinic and Mayo Foundation, Rochester, Minn.
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SNOW BLOWER SAFETY PREVENT INJURY

 

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Needle Aponeurotomy and Xiaflex update from the Hand Center of Western MA

HAND SURGERY PODCASTS

selected podcasts by Dr. Jeffrey C. Wint of the Hand Center of Western Massachusetts

 Dr. Wint recently began a series of Hand Surgery Podcaststo better explain the role of surgery to his patients.  His most popular podcast deals with Endoscopic Carpal Tunnel Release Surgery.  These Hand Surgery Podcasts are also available in ITUNES 

Needle Aponeurotomy Articles

Needle Aponeurotomy Articles

 

These review articles discuss early results of 

Needle Aponeurotomy for Duypuytren’s Disease

Dupuytrens  disesase information from the Hand Center of WMA

 

 

Dupuytrens Disease Bibliography

Dupuytren’s Disease Selected Bibliography

 

1.       Results of Surgical Treatment of Dupuytren’s Disease in Women: A Review of 109 Consecutive Patients
M.U. Anwar, S.K. Al Ghazal, R.S. Boome
Journal of Hand Surgery
November 2007 (Vol. 32, Issue 9, Pages 1423-1428)

 

2.       The Complications of Dupuytren’s Contracture Surgery
Neil W. Bulstrode, Barbara Jemec, Paul J. Smith
Journal of Hand Surgery
September 2005 (Vol. 30, Issue 5, Pages 1021-1025)

3.       Enzyme injection as nonsurgical treatment of Dupuytren's disease
Marie A. Badalamente, Lawrence C. Hurst
Journal of Hand Surgery
July 2000 (Vol. 25, Issue 4, Pages 629-636)

4.       Predicting the Outcome of Surgery for the Proximal Interphalangeal Joint in Dupuytren’s Disease
Alok Misra, Abhilash Jain, Reza Ghazanfar, Terrencia Johnston, Jagdeep Nanchahal
Journal of Hand Surgery
February 2007 (Vol. 32, Issue 2, Pages 240-245)

5.       Abductor digiti minimi involvement in dupuytren’s contracture of the small finger1
Kimberley E Meathrel, Achilleas Thoma
Journal of Hand Surgery
May 2004 (Vol. 29, Issue 3, Pages 510-513)

6.       The injection of nodules of Dupuytren's disease with triamcinolone acetonide
Lynn D. Ketchum, Terrence K. Donahue
Journal of Hand Surgery
November 2000 (Vol. 25, Issue 6, Pages 1157-1162)

7.       A congenital hand deformity: Dupuytren's disease
G. Foucher, C. Lequeux, J. Medina, R.Navarro Garcia, D. Nagel
Journal of Hand Surgery
May 2001 (Vol. 26, Issue 3, Pages 515-517)

8.       A Retrospective Review of the Management of Dupuytren’s Nodules
Rachel M. Reilly, Peter J. Stern, Charles A. Goldfarb
Journal of Hand Surgery
September 2005 (Vol. 30, Issue 5, Pages 1014-1018)

9.       Emergency microsurgical revascularization for critical ischemia during surgery for Dupuytren's contracture: A case report
Neil F. Jones, Jerry I. Huang
Journal of Hand Surgery
November 2001 (Vol. 26, Issue 6, Pages 1125-1128)

10.   Efficacy and Safety of Injectable Mixed Collagenase Subtypes in the Treatment of Dupuytren’s Contracture
Marie A. Badalamente, Lawrence C. Hurst
Journal of Hand Surgery
July 2007 (Vol. 32, Issue 6, Pages 767-774)

11.   Functional outcome after surgery for dupuytren’s contracture: a prospective study
Kingsley Paul Draviaraj, Indranil Chakrabarti
Journal of Hand Surgery
September 2004 (Vol. 29, Issue 5, Pages 804-808)

12. 12.  Collagen as a clinical target: Nonoperative treatment of Dupuytren's disease
    Marie A. Badalamente, Lawrence C. Hurst, Vincent R. Hentz
    Journal of Hand Surgery
    September 2002 (Vol. 27, Issue 5, Pages 788-798)
    
    
13. 13.  A Comparison of the Direct Outcomes of Percutaneous Needle Fasciotomy and Limited Fasciectomy for Dupuytren’s Disease: A 6-Week Follow-Up Study
    Annet L. van Rijssen, Feike S.J. Gerbrandy, Hein Ter Linden, Helen Klip, Paul M.N. Werker
    Journal of Hand Surgery
    May 2006 (Vol. 31, Issue 5, Pages 717-725)
    
    
14. 14.Metalloproteinase Gene Expression Correlates With Clinical Outcome in Dupuytren's Disease
    Phillip Johnston, Debbie Larson, Ian M. Clark, Adrian J. Chojnowski
    Journal of Hand Surgery - September 2008 (Vol. 33, Issue 7, Pages 1160-1167, DOI: 10.1016/j.jhsa.2008.04.002)
    
    
15. 15.A Complete Expression Profile of Matrix-Degrading Metalloproteinases in Dupuytren’s Disease
    Phillip Johnston, Adrian J. Chojnowski, Rose K. Davidson, Graham P. Riley, Simon T. Donell, Ian M. Clark
    Journal of Hand Surgery - March 2007 (Vol. 32, Issue 3, Pages 343-351, DOI: 10.1016/j.jhsa.2006.12.010)
    
    
16. 16.Molecular Phenotypic Descriptors of Dupuytren’s Disease Defined Using Informatics Analysis of the Transcriptome
    Samrina Rehman, Fiona Salway, John K. Stanley, William E.R. Ollier, Philip Day, Ardeshir Bayat
    Journal of Hand Surgery - March 2008 (Vol. 33, Issue 3, Pages 359-372, DOI: 10.1016/j.jhsa.2007.11.010)
    
    
17. 17.Evidence for a polyclonal etiology of palmar fibromatosis
    Howard A. Chansky, Thomas E. Trumble, Ernest U. Conrad, John F. Wolff, Lorne W. Murray, Wendy H. Raskind
    Journal of Hand Surgery - March 1999 (Vol. 24, Issue 2, Pages 339-344, DOI: 10.1053/jhsu.1999.0339)
    
    
18. 18.Factors in the Pathogenesis of Dupuytren’s Contracture
    Mohammad M. Al-Qattan
    Journal of Hand Surgery - November 2006 (Vol. 31, Issue 9, Pages 1527-1534, DOI: 10.1016/j.jhsa.2006.08.012)
    
    
19. 19.Genetic and epigenetic influences on the pathogenesis of Dupuytren's disease
    Raj H. Ragoowansi, Jonathan A. Britto
    Journal of Hand Surgery - November 2001 (Vol. 26, Issue 6, Pages 1157-1158)
    
    
20. 20.On the origin and spread of Dupuytren's disease
    Robert M. McFarlane
    Journal of Hand Surgery - May 2002 (Vol. 27, Issue 3, Pages 385-390, DOI: 10.1053/jhsu.2002.32334)
    

Dupuytrens  disesase information from the Hand Center of WMA