Dupuytren contracture is a non–inflammatory scarring of the palmar tendons. Due to the overgrowth of connective tissue, tendons are shortened, the extension of one or more fingers is limited, flexion contracture develops with partial loss of hand function. It is accompanied by the appearance of a dense knotted string in the area of the affected tendons. In mild cases, there is a slight restriction of extension, with progression, stiffness or even ankylosis (complete immobility) of the damaged finger or fingers may develop. Treatment is usually surgical.
ICD 10
M72.0 Palmar fascial fibromatosis [Dupuytren]
Meaning
Dupuytren contracture (palmar fibromatosis) is the excessive development of connective tissue in the area of the flexor tendons of one or more fingers. The process is localized in the palm of your hand. Develops gradually, occurs for unexplained reasons. Leads to restriction of extension and formation of flexion contracture of one or more fingers. Conservative methods are used in the early stages of the disease, but the most effective way of treatment is surgery.
Dupuytren contracture is a fairly common disease in orthopedics and traumatology, which is more often observed in middle–aged men. In half of the cases, it is bilateral in nature. In about 40% of cases, the ring finger is affected, in 35% – the little finger, in 16% – the middle finger, in 2-3% – the first and second fingers. In women, it is detected 6-10 times less often and proceeds more favorably. When it occurs at a young age, it is characterized by a faster progression.
Dupuytren contracture causes
Dupuytren contracture is not associated with disorders of protein, carbohydrate or salt metabolism. Some authors claim that there is a definite connection between the occurrence of the disease and diabetes mellitus, but this theory has not yet been proven.
There are also traumatic (due to trauma), constitutional (hereditary features of the structure of palmar aponeurosis) and neurogenic (peripheral nerve damage) theories, but the opinions of scientists remain contradictory. The constitutional theory is supported by hereditary predisposition. In 25-30% of cases, patients have close blood relatives suffering from the same disease.
Classification
Taking into account the severity of symptoms , there are three degrees of Dupuytren contracture:
- First. A dense nodule with a diameter of 0.5-1 cm is found on the palm. There is a weight located on the palm or reaching the area of the metacarpophalangeal joint. Sometimes soreness is detected during palpation.
- The second. The weight becomes more coarse and rigid, spreads to the main phalanx. The skin also becomes rough and solders with palmar aponeurosis. Visible funnel-shaped depressions and retracted folds appear in the affected area. The affected finger (or fingers) are bent in the metacarpophalangeal joint at an angle of 100 degrees, extension is impossible.
- Third. The severity extends to the middle, less often to the nail phalanx. Flexion contracture with an angle of 90 degrees or less is detected in the metacarpophalangeal joint. Extension in the interphalangeal joint is limited, the degree of restriction may vary. In severe cases, the phalanges are located at an acute angle to each other. Subluxation or even ankylosis is possible.
The rate of progression of Dupuytren contracture is difficult to predict. Sometimes a slight restriction persists for several years or even decades, and sometimes only a few months pass from the appearance of the first symptoms to the development of stiffness. It is also possible to have a long-term stable course, which is replaced by rapid progression.
Dupuytren contracture symptoms
Pathology has a very characteristic clinical picture, which is difficult to confuse with the symptoms of other diseases. On the palm of the patient, a seal formed by a node and one or more subcutaneous cords is revealed. The extension of the finger is limited.
The first sign of the development of Dupuytren contracture usually becomes a seal on the palm surface of the hand, usually in the area of the metacarpophalangeal joints of the IV-V fingers. Subsequently, the dense nodule slowly increases in size. There are strands extending from it to the main, and then to the middle phalanx of the affected finger. Due to the shortening of the tendon, contracture is first formed in the metacarpophalangeal joint, and then in the proximal (located closer to the center of the body) interphalangeal joint.
The skin around the node becomes denser and gradually solders with the underlying tissues. Because of this, bulges and retractions appear in the affected area. When trying to straighten the finger, the knot and the strings become clearer, clearly visible.
Usually Dupuytren contracture is formed without pain and only about 10% of patients complain of a more or less pronounced pain syndrome. Pain, as a rule, is given to the forearm or even the shoulder. Dupuytren contracture is characterized by a progressive course. The rate of progression of the disease can fluctuate and does not depend on any external circumstances.
Diagnostics
The diagnosis of Dupuytren contracture is made based on the patient’s complaints and the characteristic clinical picture. During the examination, the doctor palpates the patient’s palm, identifying knots and cords, and also evaluates the amplitude of movements in the joint. Additional laboratory and instrumental studies are usually not required to confirm the diagnosis.
Dupuytren contracture treatment
Traumatologists-orthopedists are engaged in the treatment of pathology. Treatment can be both conservative and operative. The choice of methods is made taking into account the severity of pathological changes. Conservative therapy is used in the initial stages of Dupuytren conjuncture. The patient is prescribed physiotherapy (thermal procedures) and special exercises for stretching palmar aponeurosis. Removable splints can also be used to fix the fingers in the extension position. As a rule, they are worn at night and removed during the day.
With persistent pain syndrome, therapeutic blockades with hormonal drugs (diprospan, triamcinolone, hydrocortisone, etc.) are used. The solution of the drug is mixed with a local anesthetic and injected into the area of the painful node. Usually, the effect of one blockade persists for 6-8 weeks. It should be borne in mind that the use of hormones is one of the methods of treatment that should be used with caution. Conservative remedies cannot eliminate all manifestations of the disease. They only slow down the rate of contracture development. The only radical way of treatment is surgery.
There are currently no clear recommendations on the severity of symptoms for which surgical treatment is necessary. The decision on surgical intervention is based on the rate of progression of the disease and the patient’s complaints of pain, restriction of movement and related difficulties in self-care or performing professional duties.
Usually doctors recommend surgery in the presence of flexion contracture with an angle of 30 degrees or more. The purpose of the operation, as a rule, is to excise scar tissue and restore the full range of movements in the joints. However, in severe cases, especially with long–standing contractures, the patient may be offered arthrodesis (the creation of a fixed joint with the fixation of the finger in a functionally advantageous position) or even amputation of the finger.
Reconstructive surgery for Dupuytren contracture can be performed under general anesthesia or local anesthesia. With pronounced changes on the part of the skin and palmar aponeurosis, surgical intervention can be quite long, so in such cases general anesthesia is recommended.
There are many incision options for Dupuytren contractures. The most common is a transverse incision in the area of the palmar fold in combination with L- or S-shaped incisions along the palmar surface of the main phalanges of the fingers. The choice of a specific method is made taking into account the peculiarities of the location of the scar tissue. During the operation, the palmar aponeurosis is completely or partially excised. In the presence of extensive adhesions, which are usually accompanied by thinning of the skin, dermoplasty with a free skin flap may be required.
Then the wound is sutured and drained by a rubber graduate. A tight pressure bandage is applied to the palm, which prevents the accumulation of blood and the development of new scarring changes. The hand is fixed with a plaster splint so that the fingers are in a functionally advantageous position. Stitches are usually removed on the tenth day. Subsequently, the patient is prescribed therapeutic gymnastics to restore the volume of movements in the fingers.
Prognosis and prevention
The outcome is usually favorable, after excision of the fibrosis areas, the movements of the brush are restored in full. Sometimes (especially with early onset and rapid progression), a recurrence of contracture may occur over several years or decades. In this case, a repeat operation is required. Prevention has not been developed.
Literature
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