Dupuytren's Cotracture -dnbid

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Dupuytren’s Contracture:

Dupuytren’s Contracture Dr. D. N. Bid [PT]

Definition: :

Definition: Dupuytren's Fasciitis and Contracture - a disease of the palmar fascia resulting in progressive thickening and contracture of fibrous bands on the palmar surface of the hand and fingers. dnb 2

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Basically, the tissue on the palm side of the hand thickens (can become as thick as 0.5cm) and essentially "shrinks" and produces a tightness in the area of the hand which the diseased tissue overlies. dnb 3

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It occurs most often in the fourth and fifth digits (ring and small fingers). It is a very common problem and often arises in the hands of middle aged persons;  however, it can be seen as early as the twenties. This entity does run in families in some cases.  It is seven times more common in men than women. dnb 4

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It has been associated with diabetes and can be seen in alcoholics with cirrhosis of the liver. It has also been associated with epilepsy but may be a result of the use of anticonvulsant drugs rather than the presence of epilepsy itself. dnb 5

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Signs and symptoms: :

Signs and symptoms : The patient usually first notices a painless small hard lump below the skin in the mid palm at the base of the ring or little finger. As the disease progresses, the overlying skin becomes increasingly puckered and rough bands of thickened tissue can be felt over the affected area. dnb 7

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The first and second joints of the affected finger eventually become pulled down from the thickening and contracture of the tissue. dnb 8

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The patient may complain that he/she cannot straighten the ring and little fingers, or that there is "a knot in my palm". The distal joint remains unaffected.  The joints themselves remain unaffected, but in long-standing cases the joints can become stiff from limited motion. dnb 10

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The severity of the contracture varies from patient to patient and even in the same patient as the disease may progress. In more severe cases, the middle, index, and long fingers and even the thumb can become affected. dnb 11

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The order of most common involvement of the fingers is:  ring, small, long, thumb, then index. The patient may notice thickening over the dorsal side of the finger joints (termed knuckle pads). dnb 12

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If the patient's foot (feet) is (are) involved, this usually takes the form of a firm nodule under the instep of the foot. dnb 13

Possible causes: :

Possible causes: As mentioned earlier, there has been an association of this condition with systemic diseases (for e.g., diabetes), epilepsy, Celtic races, and chronic alcoholism. However, this may be more coincidental than an actual cause and effect relationship between these entities. There is no known relationship in most cases and is therefore idiopathic. dnb 14

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There has been a case described in the literature of Dupuytren's contracture arising in a patient following burns to the upper extremity. A recent article found an increased risk of Dupuytren's contracture in smokers. dnb 15

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GRADES:

GRADES

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Grade I – thickened nodule & band in PA  skin tethering & puckering – full movt. Grade II – peritendinous bands involved  extension of fingers limited. Grade III – flexion contracture.

Treatment Options: :

Treatment Options: The only effective treatment option for this condition is surgical . However, if the patient's condition is stable and the disease is not progressing, then the risks of surgery must be weighed against the actual decrease in the patient's quality of life due to the disease, especially in elderly patients. dnb 19

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The patient is instructed to use heat, perform stretching exercises, and massage the palm for early treatment, in an attempt to maintain flexibility and function. dnb 20

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Once significant functional loss has occurred, surgical treatment is justified. If only one area of the palm is involved and only one scarred band is present, then the surgeon may be able to only cut this band for relief of the contracture. dnb 21

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This procedure is simple, but the disease has a high rate of recurrence. However, if the problem is more extensive, then the only effective option is to surgically remove the diseased fascia (termed fasciectomy ). dnb 22

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This will only solve the problem in the area removed;  patients with this condition are more likely to have the condition arise in other areas, especially if there is a hereditary component to the patient's condition. Surgical management is appropriate when the joint contracture exceeds 30 degrees . dnb 23

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In most cases, the surgery can be carried out under local anesthesia on an outpatient basis. Depending on the extent of involvement, the surgeon will remove all or part of the palmar fascia. The surgery involves raising skin flaps and carefully dissecting out the diseased fascia without injuring nerves which may run through the thickened tissue. dnb 25

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After the surgery has been performed and the incisions have healed, the patient begins an intensive program of hand rehabilitation to restore full use of the affected digits. This involves stretching, active motion exercises, and nighttime extension splinting to restore a full ROM. dnb 26

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The manifestations of Dupuytren’s disease are variable and may be confined to a single digit, but palmer and digital involvement of the ring and small fingers is more common. Diffuse involvement of the first web space and thumb in addition to the fingers is less common. 27 dnb

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No exact criteria exist for surgical intervention in Dupuytren’s disease. Some patients who have severe MCP and PIP joint contractures have surprisingly few complaints of functional disability, whereas some patents with pretendinous cords and nodules without contractures desire surgical intervention. 28 dnb

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Guidelines for surgical intervention include: 30 degrees of MCP joint contracture. 15 degrees of PIP joint contracture. Inability to place the hand into a pocket, lay it flat on a table, or bring it together with the opposite hand (as in prayer). 29 dnb

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Regardless of the criteria used for surgical intervention, the PIP contracture is the most difficult to correct and warrants early intervention. 30 dnb

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Surgical procedure used in the Rx of Dupuytren’s Contracture include: subcutaneous fasciotomy , partial selective fasciectomy , complete fasciectomy , fasciectomy with skin grafting , and amputation . dnb 31

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Subcutaneous fasciotomy In elderly patients with MCP joint contracture, subcutaneous fasciotomy is ideal, regardless of whether one or two digits are involved. This procedure may be done in the office with local anesthesia. 32 dnb

Subcutaneous fasciotomy Rehab Protocol :

Subcutaneous fasciotomy Rehab Protocol 0-7 days Encourage the patient to work on stretching exercises immediately after the surgery . Maintain digital extension with resting pan splint with Velcro or straps. Have the patient wear the splint during the day between exercises and at night for the first week. Continue night splints for 6 weeks after surgery. 33 dnb

POST OPERATIVE treatment:

POST OPERATIVE treatment GOALS - Maintain the correction - reduce postop edema - prevent scarring - restore preoperative flexion & grip strength

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Therapy begins 2-5 days postop. Volar forearm based splint with wrist in neutral & fingers in extension as much as possible. thumb is splinted in extension to minimize web-space contracture. To start immediate active ROM ex of flexion & extension. Passive stretching as per pain tolerance

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Attention to be paid to PIP jt [to overcome collateral ligament & capsular contracture.] Jt block ex required to regain DIP jt flexion [esp if hyperextension was present preop] 2 nd postop week, splinting during day time is weaned. Encourage the use of hand Nighttime use of splint continued up to 6 months.

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Scar management -Massage with silicone gel STRENGHTHENING EXERCISES: - begin once wound gets healed - 3 wks after primary closure

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Thank you for your attention…… 38 dnb