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Dupuytren’s contracture is a disease characterized by thickening and shortening of fibrous bands of skin (fascia) in the palm (palmar fascia). It is believed to be a hereditary disorder. It most commonly results in contracture of the ring and little fingers (fourth and fifth fingers), although not all individuals diagnosed with Dupuytren’s disease develop contracture.
Surrounding the muscles, bones, and joints is a tough layer of connective tissue that lends structural support and shape. Collagen is the primary constituent of connective tissue, and its fluid properties change according to forces imposed on it. Under lasting tension it will shorten, harden, and lose its elasticity. In Dupuytren's contracture, the fascia in the palm of the hand form nodules and cords of thickened tissue that may extend into the fingers. As these changes progress, increasing tension causes the fingers to relentlessly flex toward the palm (flexion contracture). In individuals with a rare but severe familial Dupuytren’s diathesis, lesions similar to those on the palm may develop in the connective tissue of the knuckle pads (dorsum) of the fingers (Garrod’s nodes), soles of the feet (Ledderhose disease), or rarely, in some males, the penis (Peyronie’s disease).
Dupuytren's contracture usually develops and progresses slowly over several years, although some flexion contractures develop rapidly in just a few weeks or months. In 65 percent of cases, both hands are affected (bilateral) (Revis).
Risk: About four-fifths of people with this disease are male, and in 27% to 68% of individuals with Dupuytren's contracture, there is a family history of the condition (Revis). Risk is increased in individuals who smoke or who consume alcohol regularly and in those who have epilepsy, diabetes mellitus, AIDS, tuberculosis, or cirrhosis of the liver. Incidence and Prevalence: In the US, approximately 5% to 15% of men older than 50 years are affected (Revis). |
Source: Medical Disability Advisor
History: The individual may report first noticing thickened skin on the palm of one hand and then the formation of a firm lump of tissue on the palm. Individuals may complain of discomfort when using tools because the "lump" in the palm makes forceful gripping painful. The deformity and limited ability to open the hand to grasp large objects compels the individual to seek medical attention. Physical exam: The skin of the palm noticeably puckers or “dimples.” Small hard nodules may be visible under the skin on the palm of the hand, spreading to form a hard band of tissue that may extend to the fingers. Tissue nodules may be sensitive to touch. Soft pads ("knuckle pads" or Garrod’s nodes) may be seen on the tops of the middle joints of the involved fingers. In the tabletop test, the affected individual is not able to simultaneously place both the palm and fingers flat on a tabletop. Flexion contracture of the third, fourth, and/or fifth fingers may be seen. Tests: Although x-rays may show some contractures of the joints, no specific tests are necessary to make the diagnosis. |
Source: Medical Disability Advisor
Treatment may not be needed for slowly progressing disease with no pain and little impact on hand mobility. In the early stages of Dupuytren's contracture, treatment includes physical therapy and corticosteroid injections into the growing nodules. A minimally invasive procedure (needle aponeurotomy) can be done to puncture and divide cords of tissue that contract fingers, helping to straighten the affected fingers. This is not a permanent solution because the disease may recur and progress; it is primarily used for elderly individuals or patients in poor health. Radiation therapy may also be used in the early stages to slow the disease process before connective tissue cells have begun to multiply significantly or to produce scarring. Collagenase injections using an enzyme derived from bacteria (Clostridium histolyticum) have shown promise in treating Dupuytren’s contracture, but long-term follow-up of this treatment is required before more widespread use (Townsend).
Five types of hand surgery are used to treat Dupuytren’s disease: subcutaneous fasciotomy, partial (selective) fasciectomy, complete fasciectomy, fasciectomy with skin grafting, and amputation. The surgical decision will depend on the degree of contracture present, patient’s age and general health, patient’s occupation, status of the skin of the palm, and presence of bony deformity, if any.
Dupuytren’s release describes either fasciotomy, the surgical release of tissue, or fasciectomy, some degree of surgical removal of tissue. Subcutaneous fasciotomy is the least extensive procedure and is usually reserved for elderly or infirm individuals. It involves using a scalpel to make skin puncture wounds in the thickened fibrous bands across the palm to temporarily reduce tension in the cords. Partial fasciectomy is indicated when one or two fingers are involved; it excises only mature deformed tissue, not all diseased tissue. Complete fasciectomy is usually necessary when the condition becomes so severe that it limits joint motion and impedes hand function. A commonly cited threshold for this surgery is a positive tabletop test, in which the individual cannot simultaneously place both the palm and fingers flat on a tabletop. During the surgery, the bands of thickened, abnormal tissue under the skin are removed (fasciectomy), allowing better joint motion. Fasciectomy with skin grafting is indicated in younger individuals with a poorer prognosis because of epilepsy, alcoholism, recurrence of lesions, or signs of Dupuytren’s diathesis in other parts of the body. Amputation of affected fingers is rarely performed but may be indicated in severe contractions that cannot be corrected sufficiently to restore usefulness of the fingers or hand. |
Source: Medical Disability Advisor
The disease is progressive, and restriction in motion that increases with time will usually require surgery. Without surgical intervention, deformity and impairment become permanent. The success of the surgery is determined by the severity of the contractures and the number of digits involved. The more firmly fixed the contracted tissue becomes (because of compromised elasticity), the less likely it is that surgery will produce a satisfactory outcome. Surgical correction removes abnormal tissue to restore movement. However, recurrence of this condition is common, even after surgery.
Partial fasciectomy has a recurrence rate of 50% (Revis). |
Source: Medical Disability Advisor
Common clinical practice indicates that nonoperative treatment for Dupuytren's contracture is ineffective. The success of range of motion exercises or splinting of the diseased tissue prior to surgery is not supported by scientific evidence. Restorative rehabilitation begins after the surgical release of the Dupuytren's contracture (Abbott; McFarlane 2002; McFarlane 1997; Ross).
Before surgical intervention, rehabilitation may be indicated to support the individual's independence in performing common tasks. As the contracture develops, the subject increasingly loses the ability to fully open the palm to grasp and hold objects. Modifications to tools or use of assistive devices may facilitate the completion of tasks of daily living and work requirements (Eckhaus; McFarlane 2002; McFarlane 1997).
Additional information may provide insight into the rehabilitation needs of these individuals (Yi). |
FREQUENCY OF REHABILITATION VISITS | | Nonsurgical Table (contracture) | |
| Occupational / Hand / Physical Therapist | | Up to 2 visits within 2 weeks | | | | | | | | Surgical (release) | |
| Occupational / Hand / Physical Therapist | | Up to 32 visits within 16 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Complications are frequent, including hematoma formation, joint stiffness, and delayed healing. The procedure does not prevent recurrence. Fixed contraction deformities of the hand may interfere with normal hand function. |
Source: Medical Disability Advisor
| Depending on the nature of the work and the individual's job requirements, specific restrictions or accommodations may have to be made, especially if the dominant hand is affected or both hands are involved. The individual may have to change job functions that use the involved hand. After surgery, immobilization of the hand and postoperative rehabilitation will preclude using the involved hand until healing is complete. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have epilepsy or diabetes mellitus?
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Does individual smoke or consume alcohol regularly?
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Did individual seek medical attention secondary to difficulty using the hand?
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On exam, were skin puckers found? Were small hard nodules found under the skin on the palm of the hand?
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Does individual have soft pads called "knuckle pads" on the tops of the middle joints of the involved fingers?
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Was tabletop test performed?
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Were x-rays performed?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Did individual have a favorable response from physical therapy?
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Has individual had corticosteroid injections into the nodules?
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Have fingers and hand been splinted?
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Was a needle aponeurotomy or subcutaneous fasciotomy performed for short-term relief of immobility?
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Was a partial or complete fasciectomy performed? Were skin grafts needed?
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Did postsurgical complications develop such as hematoma, stiffness, or failure to heal?
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Has individual had a recurrence?
Regarding prognosis:
- Is individual active in physical therapy?
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Does individual have a home exercise program?
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Is individual's employer able to accommodate any necessary restrictions?
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Does individual have any conditions that may affect the ability to recover?
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Does individual have any fixed contraction deformities?
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Source: Medical Disability Advisor
| CitedRevis, Don R. "Dupuytren Contracture." eMedicine. Eds. Carlos J. Lozada, et al. 30 Nov. 2007. Medscape. 29 Jan. 2009 <http://emedicine.com/med/topic592.htm>.Netscher, D., and N. Fiore. "Chapter 74, Section XIII - Hand Surgery." Sabiston Textbook of Surgery. Ed. C. M. Townsend. 18th ed. St. Louis: Saunders, 2008. |
| RehabilitationAbbott, K., et al. "A Review of Attitudes to Splintage in Dupuytren's Contracture." Journal of Hand Surgery - British and European Volume 12 3 (1987): 326-328. National Center for Biotechnology Information. National Library of Medicine. 18 Sep. 2008 <PMID: 3437198>.Eckhaus, D. "Dupuytren's Disease." Hand Rehabilitation: A Practical Guide. Eds. Gaylord L. Clark, et al. 2nd ed. New York: Churchill Livingstone, Inc., 1998. McFarlane, R. M., and J. C. MacDermid. "Dupuytren's Disease." Hunter - Mackin - Callahan Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. McFarlane, Robert M. "Dupuytren's Disease." Journal of Hand Therapy 10 1 (1997): 8-13. National Center for Biotechnology Information. National Library of Medicine. 18 Sep. 2008 <PMID: 9116811>. Ross, D. C. "Epidemiology of Dupuytren's Disease." Hand Clinic 15 1 (1999): 53-62. National Center for Biotechnology Information. National Library of Medicine. 18 Sep. 2008 <PMID: 10050242>. Yi, I. S., G. Johnson, and M. S. Moneim. "Etiology of Dupuytren's Disease." Hand Clinic 15 1 (1999): 43-51. National Center for Biotechnology Information. National Library of Medicine. 18 Sep. 2008 <PMID: 10050241>. |
Source: Medical Disability Advisor
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