Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Dupuytren's Contracture


Related Terms

  • Dupuytren's Disease
  • Flexion Contracture

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physical Therapist
  • Plastic Surgeon

Comorbid Conditions

Factors Influencing Duration

Individuals with Dupuytren’s typically work in their usual job until the disease makes continuing so difficult that surgical treatment occurs.

After surgery, the factors include whether the dominant hand was involved, the extent and severity of the condition, the extent of the surgery required to correct the condition, the development of complications, individual compliance with physical/occupational therapy requirements, the individual's age and general health, the presence of accompanying underlying conditions, and the individual's job requirements. If the contralateral hand is also involved, and the individual does not have a normal hand on either side, activities of daily living and work tasks are more challenging. The willingness of the employer to allow for accommodated work is key (Melhorn).

Medical Codes

ICD-9-CM:
728 - Disorders of Muscle, Ligament, and Fascia
728.6 - Contracture of Palmar Fascia; Dupuytrens Contracture

Overview

© Reed Group
Dupuytren's contracture (Dupuytren's disease) is a disease characterized by thickening of fibrous bands (cords) of skin and underlying tissue in the palm (palmar fascia) than can result in the band shortening. As the bands shorten or contract, the fingers pull down into the palm (flexion contracture). The bands are so strong that the individual becomes unable to straighten (extend) his or her involved fingers.

Dupuytren's contracture is a hereditary disorder with strong epidemiological evidence (Hu). In a study from Europe, where the disease is common, six of nine genetic loci found associated with genetic susceptibility to Dupuytren's disease contained genes encoding proteins in the Wnt-signaling pathway, which can lead to cellular proliferation (Dolmans).

The disease (contracture) is most common in the palm, extending into the ring and little fingers (fourth and fifth fingers), causing the flexion contracture. The severity of the disease varies with some individuals developing only nodules (bumps in palm) without the flexion contractures.

The fibrous bands develop in the tough layer of connective tissue immediately underneath the skin of the palms or soles that lends structural support and shape to the palm and sole of the foot. Collagen is the primary constituent of connective tissue, and its 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 forms nodules and cords of thickened tissue that may extend into the fingers— resulting from a change in the type of collagen (Bailey, Murrell). 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 months. In 65% of cases, both hands are affected (bilateral) (Revis).

Incidence and Prevalence: In genetically predisposed populations in Europe and Australia, approximately 5% to 15% of men older than 50 years are affected (Revis). Due to the multi-ethnicity of the US. Population, the disease is less common. There is an increased risk with age and with diabetes.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Dupuytren’s disease is 3 times more common in men than women (Anthony). There is positive family history in 27% to 68% of individuals with Dupuytren's contracture (Revis). Risk may be increased with smoking, regular consumption of alcohol , epilepsy, diabetes mellitus, AIDS, tuberculosis, and or cirrhosis of the liver. For more information on the role of diabetes and genetic factors, please refer to "Disease and Injury Causation," page 151.

Source: Medical Disability Advisor



Diagnosis

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 in the palm (called a nodule). This may often look like a callus but is in the palm, not over the "palmar kuncle" area. Individuals may complain of discomfort when using tools because the "lump" in the palm can make forceful gripping painful. The loss of function in the form of a flexion 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" (Dupuytren’s pit). Small hard nodules (Dupuytren’s 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 initially but usually are not painful except from direct pressure during forceful gripping. Soft pads ("knuckle pads" or Garrod’s nodes) may rarely be seen on the tops of the middle joints of the involved fingers. The tabletop test, in which the affected individual is not able to simultaneously place both the palm and fingers fully flat on a tabletop is used as an indication for surgery. The flexion contracture usually starts with the ring finger, then little finger, and then the middle finger. In Dupuytren’s diastema, a rare more aggressive and progressive form of the disease, all fingers may eventually become affected.

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

Treatment may not be needed for slowly progressing disease with no pain and little impact on hand function. 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 will recur and progress; it is primarily used for elderly individuals or patients in poor health. Radiation therapy is no longer recommended. 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 (Netscher).

Dupuytren's release refers to a type of hand surgery (fasciotomy or fasciectomy) performed to release abnormal tightening and flexing inward (flexion contracture) of one or more fingers or thumb as a result of abnormal connective tissue growth in the palm. Two types of procedures are available for release of the Dupuytren’s contracture: (1) Injection of a prescription medication (collagenase clostridium histolyticum) that breaks down the collagen cord or (2) surgery. Surgery can be open (requires an incision) or percutaneous (small needle inserted multiple times into the cord). Open can involve partial removal of the offending contracture tissue or complete removal. The most common open procedure is the partial palmar fasciectomy. This procedure involves making an incision or incisions in the palm of the hand to remove the contracted connective tissue (fascia) that covers, supports, and separates the tendons and muscles of the hand, fingers, and thumb. In patients with advanced disease and more severe flexion contractures, additional surgery may be necessary as the finger PIP joints may have stiffened in flexion, and may require capsulectomy (additional surgery) to regain part of the motion they have lost.

For individuals who have neglected to seek care until the tip finger is permanently fixed to the palm, the only surgery may be to amputate the involved digit.

The extent of surgery and the rehabilitation varies according to how large the area of involvement is (the contracture), as well as the severity of disease and contractures, history of previous surgical treatment, the individual's age, occupation, and health status.

Source: Medical Disability Advisor



Prognosis

The disease is progressive and restriction in motion that increases with time will usually require either collagenase injection or surgery. Without collagenase injection or surgical intervention, deformity and impairment become permanent. The success of the both treatments is determined by the severity of the contractures and the number of fingers involved. The more firmly fixed the contracted tissue becomes (because of compromised elasticity), the less likely it is that either treatment will produce a satisfactory outcome. Collagenase injection creates gaps in the fascial cord while surgery removes the abnormal tissue to restore movement. Since this in an inherited disease, the condition will recur. Thus if the person lives long enough, multiple operations may be necessary over years.

Source: Medical Disability Advisor



Rehabilitation

Common clinical practice indicates that nonoperative treatment for Dupuytren's contracture is ineffective. However, unless significant disabling contractures (functional loss) are present (usually those with greater than 15 degree flexion contractures at the proximal interphalangeal joint and greater than 30 degrees at the metacarpophalangeal joint), collagenase injection or surgery may not be necessary (Canale). The success of range of motion exercises or splinting of the diseased tissue prior to surgery is not supported by scientific evidence. Steroid injections and needle fasciotomy are reported as sometimes helpful (Rayan).

The procedures (surgical or injection) and the degree of contracture dictates the type, duration, and intensity of rehabilitation following Dupuytren's release. Once the wound is closed, early return to modified work results in better outcomes. (Early return to work is possible with modification of activities.) Once the wound is closed, gradual increasing activities at home and work reduce unnecessary disability (lost work time) and improve functional outcomes (Melhorn).

Restorative rehabilitation begins after the surgical release of the Dupuytren's contracture. It includes elevation, active range of motion exercises, and progressive strengthening that utilizes therapeutic putty (Abbott; Canale; McFarlane 2002; McFarlane 1997; Ross). Following collagenase injection or surgical release, the individual may be instructed to wear a night splint for 3 months to support the contracture correction (Canale).

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 adaptive equipment may facilitate the completion of tasks of daily living and work requirements, particularly if vibratory tools are being used (Melhorn).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical Table (contracture)
SpecialistDupuytren's Contracture
Occupational / Hand / Physical TherapistUp to 2 visits within 2 weeks
Surgical (release)
SpecialistDupuytren's Contracture
Occupational / Hand / Physical TherapistUp to 16 visits within 16 weeks
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

Complications are frequent, including hematoma formation, joint stiffness, and delayed wound healing. Injury to the sensory digital nerves that frequently wrap around the Dupuytren’s cord may occur during surgery leaving a finger with decreased sensation and decreased dexterity. The procedure does not prevent recurrence. Fixed contraction deformities of the hand, despite surgery, may interfere with normal hand function.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

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. For additional information concerning risk, capacity, and tolerance, please refer to "Work Ability and Return to Work," pages 9-20. For information concerning the return to work phase of recovery, please refer to "Work Ability and Return to Work," pages 47-67.

Risk: The risk of reinjury is low. Again, the disease is inherited. Specific work-like activities have insufficient evidence of causation except for vibration, which demonstrated strong evidence. Therefore returning to work should consider modification for vibration activities in hands involved with Dupuytren’s disease. For more information, refer to "Disease and Injury Causation," page 147.

Capacity: Capacity is dependent on multiple factors. First, wound healing is key. It is dependent on the number of involved fingers, size of the incision, and the age of the individual. Second, although the capacity for grip and lifting may initially be limited, the willingness of employer and employee to return to modified work can allow for gradual return to increasing function. Once at work the willingness of the immediate supervisor to provide modified work activities using the guides provided by the physician. Although the hand function may be limited as a result of residual permanent flexion contractures (limited ability to open the hand wide enough to grip or hold large objects),individuals are rarely permanently disability from work activities.

Tolerance: Often the hand is sore or painful after the surgery. Wound healing takes time. Each individual tolerates pain differently. The level of pain will determine the individual’s willingness to return to work. Although a collagenase injection may be less painful, the patient will often be cautioned to limit lift and grip for three weeks to reduce the risk of rupture of the adjacent flexor tendons.

Accommodations: Accommodations are essential for early return to work and reduction of unnecessary disability. Although the individual may be at low risk for reinjury and have the capacity to perform modified work with minimal pain (demonstrating that their tolerance is high), if the employer is unwilling to provided accommodations, the individual cannot return to work (Melhorn) For example, self-employed individuals with control over the job environment might return the next day, whereas employed individuals doing heavy work will require workplace modifications. For more information, refer to "Work Ability and Return to Work," page 23.

Source: Medical Disability Advisor



Maximum Medical Improvement

8 to 12 weeks post surgery

Continued improvement is possible over 18 months, but the amount of improvement is limited.

Source: Medical Disability Advisor



Failure to Recover

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:

  • Was a definitive diagnosis of Dupuytren’s disease made with objective finding?
  • Were x-rays performed to evaluate for other conditions (co-morbidity)?
  • Have conditions with similar symptoms been ruled out?
  • Is one hand involved, or are both hands involved? Are the feet also involved? (may limit standing, walking, carrying, etc.)

Regarding treatment:

  • What treatment has the individual received?
  • Did postsurgical complications develop such as hematoma, stiffness, or failure to heal?
  • Has individual had a recurrence?
  • Was the employer willing to provide modified work?
  • Is additional surgery on the involved hand or the contralateral hand planned?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect the ability to recover?
  • Does individual have any fixed contraction deformities?
  • Is the disease progressing during medical follow up?

Source: Medical Disability Advisor



References

Cited

Abbott, 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>.

Anthony, S. G. , et al. "Gender ratio of Dupuytren's disease in the modern U.S. population." Hand (NY) 3 (2) (2008): 87-90.

Bailey, A. J. , et al. "Collagen of Dupuytren's disease." Clinical Science & Molecular Medicine 53 (5) (1977): 499-502.

Dolmans, G. H. , P. M. Werker, and H. C. Hennies. "Wnt signaling and Dupuytren's disease." New England Journal of Medicine 365 (2011): 307-317.

Eckhaus, D. "Dupuytren's Disease." Hand Rehabilitation: A Practical Guide. Eds. Gaylord L. Clark, et al. 2nd ed. New York: Churchill Livingstone, Inc., 1998.

Genovese, E. , and M. H. Hyman. "Chapter 9 - Occupational Risk Factors for Dupuytren's Disease(DD)." Guides to the Evaluation of Disease and Injury Causation. Eds. Mark J. Melhorn and William E. Ackerman. American Medical Association, 2008. 147-152.

HU, F. Z. , et al. "Mapping of an autosomal dominant gene for Dupuytren's contracture to chromosome 16q in a Swedish family." Clin Genet 68 5 (2005): 424-429.

McFarlane, R. M., and J. C. MacDermid. "Dupuytren's Disease." 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>.

Melhorn, J. M. Unpublished paper given at the 14th Annual Occupational Orthopaedics and Workers' Compensation: A Multidisciplinary Perspective. Eds. J. M. Melhorn and E. J. Carragee. American Academy of Orthopaedic Surgeons, 2012.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Murell, G. A. "The role of the fibroblast in Dupuytren's contracture." Hand Clinic 7 (4) (1991): 669-680.

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.

Rayan, Ghazi M. "Non-operative Treatment of Dupuytren's Disease." Journal of Hand Surgery 33A (2008): 1208-1210.

Revis, Don R. "Dupuytren Contracture." eMedicine. Eds. Carlos J. Lozada, et al. 30 Nov. 2007. Medscape. 29 Jan. 2009 <http://emedicine.com/med/topic592.htm>.

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>.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

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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