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Dupuytren's Contracture
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Dupuytren's Contracture | ||
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Related narrative: Dupuytren's Contracture Dupuytren's Contracture is a disorder occurring usually in men between the ages of 40 and 60 years. This fibroproliferative disorder is of autosomal dominant inheritance and is commonly seen in men of Scandinavian, Irish or Eastern European descent. Patients typically present with painless nodules and cords in the palms of the hands, which may or may not progress. Progression of the disease may result in disfiguring and dysfunctional flexion contractures in the fingers and palm of the hand. The cause of this condition is unknown. Since its earliest recognition in the 1500's, a tremendous amount of work has been done investigating this disease process. The autosomal dominant genetic component and predilection for those of Eastern European decent is well recognized. Other factors include elevated tissue concentrations of certain metabolic and lysosomal enzymes, abnormal fibroblasts and myofibroblasts, higher concentrations of type III collagen and evidence of local micro-vessel ischemic changes with free radical damage. The disease is also associated with increased alcohol consumption, cigarette smoking and human immunodeficiency virus infection. Mechanical tissue damage and trauma have not been shown to be associated with the development of Dupuytren's Disease. Other conditions associated with Dupuytren's disease include Plantar Fibromatosis and Peronie's Disease. Clinically, the condition is usually painless. In advanced cases, the pathologic cords can spiral around the digital neurovascular bundles and produce paresthesias and circulatory abnormalities. The condition may cause progressive flexion contractures, such that it can become impossible to actively or passively straighten the hand and fingers. Conservative modalities involving stretching the contracting structures, massaging the nodules and cords, splinting, ultrasound and steroid injections have all been employed, however, these measures do not reverse or halt the progression of the condition. When progressive flexion contractures result in significant impairment of the patients' activities of daily living, if pain develops or if neurovascular compromise ensues, surgery is recommended. Although the exact degree of permanent contracture prompting operative intervention is debated, a contracture of 30 degrees at the metacarpophalangeal (MCP) joint or 10 - 15 degrees at the proximal interphalangeal (PIP) joint are generally agreed upon. The timing of surgery is also debated: operating too soon may be associated with an increased chance for recurrence and operating too late may have increased technical difficulty and statistically higher complication rates. Many surgical procedures have been described for treatment of Dupuytren's Disease. Total/radical palmar fasciectomy has essentially been abandoned. Dermofasciectomy involves resecting the fascia and overlying skin, however, this is rarely done except in recurrent cases or revisions. Most Hand Surgeons perform an open selective palmar fasciectomy with primary closure of the skin. This involves resection of all diseased fascia in the palm and finger while leaving adjacent fascia behind. With this technique, the skin is usually amenable to primary closure, but occasionally, skin grafts may be required. The palm and fingers are splinted full-time in extension for a few days post operatively. Then early active and passive range of motion exercises are begun. Nighttime splinting in extension may be continued for two weeks. Recovery ranges between 5 weeks and several months depending on the presence of other conditions (i.e. diabetes, vascular diseases, etc.) References: Alioto RJ, Rosier RN, Burton RI, Puzas JE: Comparative Effects of Growth Factor in Dupuytren's Tissue and Normal Palmar Fascia. J Hand Surg (Am) 1994;19:442-452. Benson LS, Williams CS, Kahle M: Dupuytren's Contracture. J Am Acad Orthop Surg 1998;6:24-35. Lubahn JD, Lister GD, Wolfe T: Fasciectomy and Dupuytren's Disease: A Comparison Between the Open-palm Technique and Wound Closure. J Hand Surg (Am) 1984:9:53-58. Smith AC: Diagnosis and Indications for Surgical Treatment. Hand Clin 1991;7:635-643. Strickland JW, Leibovic SJ: Anatomy and Pathogenesis of the Digital Cords and Nodules. Hand Clin 1991;7:645-657, 659-660.
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