Dupuytren's contracture , also called Viking disease , or palmar fibromatosis , is a fibrosing condition that characteristically presents as a firm nodularity on the palmar surface of the hand with coalescing cords of soft tissue on the webs and digits. People of northern European descent are typically affected with the highest prevalence in countries such as northern Scotland, Iceland, Norway and Australia 2. Age at presentation usually peaks around There may be an increased male predilection.
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Dupuytren's contracture is a condition in which one or more fingers become permanently bent in a flexed position. While typically not painful, some aching or itching may be present. The cause is unknown. Initial treatment is typically with steroid injections into the affected area, and physical therapy. Dupuytren's most often occurs in males over the age of Typically, Dupuytren's contracture first presents as a thickening or nodule in the palm, which initially can be with or without pain.
Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring finger ; the thumb and index finger are much less often affected. In Dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function.
The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren's contracture decreases a person's ability to hold objects. People may report pain, aching, and itching with the contractions. Normally, the palmar fascia consists of collagen type I , but in Dupuytren sufferers, the collagen changes to collagen type III , which is significantly thicker than collagen type I.
In one study, those with stage 2 of the disease were found to have a slightly increased risk of mortality, especially from cancer. According to the American Dupuytren's specialist Dr. Charles Eaton, there may be three types of Dupuytren's disease: .
Treatment is indicated when the so-called table-top test is positive. With this test, the person places their hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the table, leaving a space between the table and a part of the hand as big as the diameter of a ballpoint pen , the test is considered positive and surgery or other treatment may be indicated.
Additionally, finger joints may become fixed and rigid. The main categories listed by the International Dupuytren Society in order of stage of disease are radiation therapy , needle aponeurotomy NA , collagenase injection, and hand surgery. As of [update] the evidence on the efficacy of radiation therapy was considered inadequate in quantity and quality, and difficult to interpret because of uncertainty about the natural history of Dupuytren's disease. Needle aponeurotomy is most effective for Stages I and II, covering 6—90 degrees of deformation of the finger.
However, it is also used at other stages. Collagenase injection is likewise most effective for Stages I and II. On 12 June , Dupuytren performed a surgical procedure on a person with contracture of the 4th and 5th digits who had been previously told by other surgeons that the only remedy was cutting the flexor tendons.
Because of high recurrence rates, [ citation needed ] new surgical techniques were introduced, such as fasciectomy and then dermofasciectomy. Most of the diseased tissue is removed with these procedures. Recurrence rates are high. After removal of the wires, the joint is fixed into flexion, which is considered preferable to fusion at extension.
In extreme cases, amputation of fingers may be needed for severe or recurrent cases or after surgical complications. During the procedure, the person is under regional or general anesthesia. A surgical tourniquet prevents blood flow to the limb. A year review of surgical complications associated with fasciectomy showed that major complications occurred in In the case of a shortage of skin, the transverse part of the zig-zag incision is left open. Stitches are removed 10 days after surgery.
After surgery, the hand is wrapped in a light compressive bandage for one week. People start bending and extending their fingers as soon as the anesthesia has resolved.
It is often common to experience tingling within the first week of surgery. In , Denkler described the technique. Typically, the excised skin is replaced with a skin graft , usually full-thickness,  consisting of the epidermis and the entire dermis. In most cases the graft is taken from the antecubital fossa the crease of skin at the elbow joint or the inner side of the upper arm.
The skin on the inner side of the upper arm is thin and has enough skin to supply a full-thickness graft. The donor site can be closed with a direct suture. The graft is sutured to the skin surrounding the wound. For one week the hand is protected with a dressing. The hand and arm are elevated with a sling.
The dressing is then removed and careful mobilization can be started, gradually increasing in intensity. Segmental fasciectomy involves excising part s of the contracted cord so that it disappears or no longer contracts the finger.
It is less invasive than the limited fasciectomy, because not all the diseased tissue is excised and the skin incisions are smaller. The person is placed under regional anesthesia and a surgical tourniquet is used. The skin is opened with small curved incisions over the diseased tissue.
If necessary, incisions are made in the fingers. The cords are placed under maximum tension while they are cut. A scalpel is used to separate the tissues. They wear an extension splint for two to three weeks, except during physical therapy. The same procedure is used in the segmental fasciectomy with cellulose implant.
After the excision and a careful hemostasis , the cellulose implant is placed in a single layer in between the remaining parts of the cord.
After surgery people wear a light pressure dressing for four days, followed by an extension splint. The splint is worn continuously during nighttime for eight weeks. During the first weeks after surgery the splint may be worn during daytime.
Studies have been conducted for percutaneous release, extensive percutaneous aponeurotomy with lipografting and collagenase. These treatments show promise. Needle aponeurotomy is a minimally-invasive technique where the cords are weakened through the insertion and manipulation of a small needle. The cord is sectioned at as many levels as possible in the palm and fingers, depending on the location and extent of the disease, using a gauge needle mounted on a 10 ml syringe.
After the treatment a small dressing is applied for 24 hours, after which people are able to use their hands normally. No splints or physiotherapy are given. The advantage of needle aponeurotomy is the minimal intervention without incision done in the office under local anesthesia and the very rapid return to normal activities without need for rehabilitation, but the nodules may resume growing. A comprehensive review of the results of needle aponeurotomy in 1, fingers was performed by Gary M.
Minimal follow-up was 3 years. When a comparison was performed between people aged 55 years and older versus under 55 years, there was a statistically significant difference at both MP and PIP joints, with greater correction maintained in the older group. Gender differences were not statistically significant. Complications were rare except for skin tears, which occurred in 3.
This study showed that NA is a safe procedure that can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger people and for PIP contractures. A technique introduced in is extensive percutaneous aponeurotomy with lipografting. The difference with the percutaneous needle fasciotomy is that the cord is cut at many places. The cord is also separated from the skin to make place for the lipograft that is taken from the abdomen or ipsilateral flank.
The fat graft results in supple skin. Before the aponeurotomy, a liposuction is done to the abdomen and ipsilateral flank to collect the lipograft. The digits are placed under maximal extension tension using a firm lead hand retractor. The surgeon makes multiple palmar puncture wounds with small nicks. The tension on the cords is crucial, because tight constricting bands are most susceptible to be cut and torn by the small nicks, whereas the relatively loose neurovascular structures are spared.
After the cord is completely cut and separated from the skin the lipograft is injected under the skin. A total of about 5 to 10 ml is injected per ray. After the treatment the person wears an extension splint for 5 to 7 days. Thereafter the person returns to normal activities and is advised to use a night splint for up to 20 weeks. Clostridial collagenase injections have been found to be more effective than placebo. In a MCP joint contracture the needle must be placed at the point of maximum bowstringing of the palpable cord.
The needle is placed vertically on the bowstring. The collagenase is distributed across three injection points. After 24 hours the person returns for passive digital extension to rupture the cord. Moderate pressure for 10—20 seconds ruptures the cord. Three years later, it was approved as well for the treatment of the sometimes related Peyronie's disease. Radiation therapy has been used mostly for early-stage disease, but is unproven.
Several alternate therapies such as vitamin E treatment have been studied, though without control groups. Most doctors do not value those treatments. Laser treatment using red and infrared at low power was informally discussed in at an International Dupuytren Society forum,  as of which time little or no formal evaluation of the techniques had been completed.
Only anecdotal evidence supports other compounds such as vitamin E.
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Dupuytren's disease and related hyperproliferative disorders : principles, research, and clinical perspectives. Clinical Practice Research Datalink. DupuytrEn Treatment EffeCtiveness Trial DETECT : a protocol for prospective, randomised, controlled, outcome assessor-blinded, three-armed parallel , multicentre trial comparing the effectiveness and cost of collagenase clostridium histolyticum. Seven-year clinical outcomes after collagenase injection in patients with Dupuytren's disease: A prospective study. Content validity and responsiveness of the Patient-Specific Functional Scale in patients with Dupuytren's disease.
Dupuytren's disease is a condition that affects the fascia—the fibrous layer of tissue that lies underneath the skin in the palm and fingers. In patients with Dupuytren's, the fascia thickens, then tightens over time. This causes the fingers to be pulled inward, towards the palm, resulting in what is known as a "Dupuytren's contracture. In some patients, a worsening Dupuytren's contracture can interfere with hand function, making it difficult for them to perform their daily activities. When this occurs, there are nonsurgical and surgical treatment options available to help slow the progression of the disease and improve motion in the affected fingers. The fascia is a layer of tissue that helps to anchor and stabilize the skin on the palm side of the hand.
Dupuytren's contracture is a painless deformity of the hand in which one or more fingers in this case, the two fingers farthest from the thumb are bent toward the palm and can't be fully straightened. It results from a thickening and scarring of connective tissue under the skin in the palm of the hand and in the fingers. The condition affects a layer of tissue that lies under the skin of your palm. Knots of tissue form under the skin — eventually creating a thick cord that can pull one or more fingers into a bent position. The affected fingers can't be straightened completely, which can complicate everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands. Dupuytren's contracture mainly affects the two fingers farthest from the thumb, and occurs most often in older men of Northern European descent. A number of treatments are available to slow the progression of Dupuytren's contracture and relieve symptoms.