Dupuytrens Contracture

Dupuytren’s Contracture By Saba Kamal, OTR, CHT Hands-On-Care

Dupuytren’s Release General Information Evaluation Treatment Post Operatively

General Information More common in males - 5 th decade Females in the 6 th decade of their life More severe in Males Hereditary Component – Northern European Descent Women have greater inflammatory response to surgery May be precipitated by trauma in susceptible individual (manual labors) It is casually associated with insulin-dependent diabetes mellitus, epilepsy & chronic alcoholism

Dupuytren’s contracture Disease of the palmar fascia causing flexion contracture in the digits and thumb Also known as palmar fibromatosis which is a type of tumor Tumor – refers to swelling or enlargement Dupuytren’s contracture affects 1-2% of the population and is the most common form of fibromatosis It typically affects the palmar fascia and is progressive in nature. Lower power microscopic view of Fibromatosis of Dupuytren’s disease. In the later and more quiescent stage of the disease, the cellularity is decreased and the tissue appears more tendon like with abundant collagen and few flattened fibrocytes.

Dupuytren’s contracture Initial manifestation – is a firm nodule in the palm near the distal palmar crease MCP Joint Contracture – caused by pretendinous bands of the palmar aponeurosis PIP Joint Contracture – caused by the cords (spiral/ lateral/ central) DIP Joint Contracture – caused by the retrovascular cords Web Space Contractures – caused by the natatory ligament, may cause scissoring of fingers pulling them together. Ring and Small fingers most commonly involved Severe MCP and PIP Contractures

Nodule – Primary manifestation Intimate relation between skin and nodule – possibly starts in dermis Nodules are highly cellular Rx – Pts. May need reassurance, or injection of steroid into the area or iontophoresis, preferable to excision of nodule as Dupuytren’s tissue is likely to be formed around the area. Excision of palmar nodules can leave just as painful a scar. Common location of Nodules

Skin Pits – Pitting of the palmar skin is an early pathological manifestation. It is associated with Nodule formation and its corresponding attachment to the overlying skin via vertical fibrous extensions.

Cord – Formed from normal palmar digital fascial structure called bands Cord has no myofibroblasts and only occasional fibroblasts in its dense collagen matrix The collagen framework of the band is replaced by type III collagen in a shortened form to create a cord. The dynamics of contraction are driven by the myofibroblasts and realized in a relatively shortened longitudinal collagen structure called the cord. The Cord is always palmar to the neurovascular bundle and is in direct axis of the ray. It is a the sole source of MCP joint flexion contracture. The cord makes excision of the diseased tissue difficult because it tends to draw the surrounding soft tissue including the digital nerves. Displacement of Neurovascular Bundle in the finger. (a) by Central Cord; (b) Spiral Cord

(C) By a combination of Lateral and central cord; (D) by a combination of central and spiral cord

Garrods Nodes or Knuckle pads - 1-2% incidence. The presence of knuckle pads should alert the surgeon and therapist to the possibility of early recurrence, flare reaction and a poor prognosis. Oxygen free radicals stimulate myofibroblast proliferation & increases in type III collagen and platelet derived growth factor B. Two Theories: 1. Intrinsic Theory = metaplasia of existing fascia 2. Extrinsic Theory = arises in the fibrofatty subdermal tissue & attaches to the underlying fascia.

Grayson’s / Cleland’s Ligament Grayson’s ligament originates from the volar aspect of flexor tendon sheath, runs volar to the neurovascular bundle, and inserts into the skin. Cleland’s ligament passes dorsal to the neurovascular bundle and inserts into the skin. Grayson’s and Cleland’s ligament prevent the rotary movement of the skin around the fingers, allowing the ability to grasp objects. Grayson’s ligament may contribute to PIP flexion contracture in Dupuytren’s disease.

Indications for Surgical Intervention Surgery indicated when patient is inconvenienced or incapacitated by the contracture. 30 degree contracture at the MCP is a significant disability that justifies surgery MCP easily correctable PIP as soon as the contracture begins Since it is difficult to maintain extension gains Functional Assessment: Fingers get in the way with: washing face combing hair putting hand in pocket putting hand in glove racquet sports & golf Table top test of Hueston - place the hand & fingers prone on a table. Positive = hand won't go flat. If negative (Flat Hand) surgery is not indicated. Contracture of 2 rays

STAGING - Woodruff, 1998: Stage Description Management 1 Early palmar disease with no contracture = Leave alone 2 One finger involved, with only MCPJ contracture = Surgery 3 One finger - MCPJ + PIPJ = Surgery not easy 4 stage 3 + > one finger involved = Surgery prolonged & only partly succesful 5 Finger-in-palm deformity = consider amputation

Types of Surgery Subcutaneous Fasciotomy – Performed only when MCP joint is involved or when there may be medical contraindications to more aggressive surgery. It is done with a stab incision which releases the cord, no diseased tissue is removed, not typically used for PIP contracture. Fasciotomy – Excision of the diseased tissue, entire palmar aponeurosis is excised Closed approach – all incisions are closed after excision of diseased tissue

Fasciotomy Dermofasciectomy- Removal of the skin overlying the diseased tissue as well as underlying fascia. A full thickness skin graft is performed for coverage McCash Open Palm Technique – for simplicity and flexibility. Wound closes by secondary intention, it drains well and skin sloughs are rarely seen, thus hematomas do not occur. There is decrease pain, decrease edema, decrease stiffness.

PIP Joint Release: Gentle manipulation is preferred, followed by post-op extension splinting. Never perform volar plate capsulectomy, since it can cause stiffness Preferred method = Release Cleland's ligaments Release the fibrous flexor sheath Release the check-rein ligaments of the volar plate Release the lateral bands of the extensor mechanism (to allow the extensor tendons to shift dorsally) Can use a percut. transarticular K-wire for 7-10days. For a severe flexion contracture consider arthrodesis with digital shortening.

Evaluation – Post Op History- Duration of progression Physical Examination Range Of Motion (Op reports – pre op ROM and during surgery) Strength (not done initially after post op) Sensory Assessment secondary to involvement of neurovascular bundle Functional Assessment Duration of joint involvement (MP Contractures usually correctable since the collateral ligaments are at stretch PIP Contractures may not be as correctable since the collaterals are in a relaxed state)

Treatment – Post Op Treatment usually starts 2-3 days post op, with wound care and splinting, edema management, ROM etc. Wound Care Dressing Changes and Light AROM Xerofoam/ Adaptic can be used Splinting Static Extension splint by the 3 rd day post-op (Slight hyperextension may be given at the MCP’s as tolerated by the patient) OR (Slight flexion to prevent flare up in case of severe contracture – Extension goal can then be achieved in 2-3 weeks) Splint is worn initially at night and 2 hrs on/off during the day for exercises for 2-3 weeks (could be more varies with wound healing) For PIP contracture splint may be worn continuously for 3 wks except for hygiene and exercises Edema Management Elevation Active Exercises (differential fisting/Tendon Glides) Coban Wraps (preference to 3” coban wrap than 1” due to the even distribution of pressure

Treatment 3-4 wks Post op Scar Management- when stitches are removed scar management begins usually 2-3 weeks post op Elastomere moulds made to fit in the splint Desensitization Scar Massage Splinting – Hyperextension at MCP and IP’s can be increased with padding or remolding. Edema Management- Isotoner glove can now be given to wear during day when splint is off Exercises- Active/Passive ROM: You do not want to achieve extension gains at the cost of loosing flexion especially at MCP joint Gliding exercises, Blocking Exercises, Active and very gentle passive extension, Light Putty

Treatment 6-8 wks Post op Splinting – reduced to night splinting only May continue to 6 months to prevent recurrence Dynamic splinting may be added In some cases with Severe PIP contractures LMB splinting can be initiated Exercises- Continue with previous exercises Add Progressive strengthening Passive extension

Reasoning for Splinting Ligaments and tendons exhibit viscoelastic or time / rate dependent behavior under loading So: Stress relaxation occurs- If a tendon or ligament is held at a constant length (strain) by a load (stress), the stress required to maintain that strain reduces. This reduces rapidly during the first 6 to 8 hours of loading and then more slowly over the next few months. Creep occurs- If a tendon is held by a constant load (stress), with time, the length (strain) in the tendon will increase. This strain increases quickly at first but then increases more slowly. This phenomenon is taken advantage of by the application of plaster casts or braces to correct deformity.

Modalities After the initial phase of wound healing Hot Pack in elevation - Around 3-5 days post op – assists with edema reduction with retrograde massage Later Stage: In fist position to prevent loss of flexion Paraffin - Post suture removal, assists with scar management and reducing hypersensitivity Fluidotherapy - to increase AROM and decrease hypersensitivity Ultrasound - post suture removal for scar management (under water initially secondary to hypersensitivity, then direct)

Modalities Hi-Volt Under water: After suture removal, to reduce global edema in the hand (Negative electrode in water) TENS: to manage pain in case of CRPS or Flare reaction IFC: For pain management

Complication CRPS (Complex Regional Pain Syndrome – Incidence higher in females than males Cardinal signs of CRPS Severe pain Excessive edema Stiffness Discoloration Other Signs Trophic Sudomotor or Vasomotor sympathetic nervous system changes Fibromatosis

Complications If CRPS is diagnosed protocol should be modified Focus on resolving acute CRPS before it becomes chronic Splinting should be modified to reduce tension or discontinued since aggressive PROM is contraindicated with CRPS, Dynamic splinting could be used. Stress loading should be added..etc. Other Complication – Dehiscence Adhesions PIP contracture Poor flexion Joint stiffness

Points to remember Watch closely for recurrence PIP flexion contracture And Educate the patient to continue Night Extension Splinting for 6 months

Drawing by Saba Kamal Thank You

Dupuytrens Contracture

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Dupuytrens Contracture