Signs of Dupuytren's contracture
This is a common pathology that most often affects men. The exact reason for its development is unknown. However, French scientists argue that heredity plays an important role. The influence of injuries and overloads of the hands or metabolic disorders cannot be excluded. Often contracture affects both hands at once. At the beginning of development, nodules and skin compactions can be detected that form on the palmar surface (Fig. 1).
Fig.1. The appearance of both hands of the patient with changes in the skin of the palmar surface with a slight limitation in finger extension (own observation).
A longitudinal or fan-shaped scar gradually develops, which limits the extension of one or more fingers (Fig. 2).
Rice. 2. Appearance of the patient’s hand with limited extension of fingers 3–5 – Dupuytren’s contracture (own observation).
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1.What is Dupuytren's contracture
Dupuytren's contracture is a progressive chronic hand disease affecting the hands, resulting in impaired flexion function of the fingers. Most often, the little or ring finger on one hand or symmetrically on both limbs are affected. The disease leads to restrictions in professional activities, and in severe cases even becomes an obstacle to self-care procedures.
Dupuytren's contracture is most common among men in Scandinavia and Eastern Europe. The most likely cause of this pathology is considered to be a hereditary predisposition. It has been noted that patients with finger contractures have relatives with similar disorders. Moreover, the closeness of the relationship is inversely proportional to the severity of the disease - the more distant a relative exhibits contracture, the more severe the manifestations in the descendant to whom the disease was inherited.
Among the provoking factors, there are also conditions that contribute to the development of the disease - professional activities associated with tension in the palms, injury to them, or pinching of the nerves of the hand. The risk of developing contracture is higher among drivers working on long routes, turners and milling operators, and workers who constantly monitor the movement or position of parts on a conveyor belt.
Risk factors also include age. The disease occurs more often in older people. At the same time, the onset of Dupuytren's contracture in youth causes a more severe course and rapid progression.
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Treatment of Dupuytren's contracture
The only way to get rid of this disease is through surgery. During the operation, which is performed under general anesthesia, scar tissue is removed. And then doctors perform skin grafting of the wound, which serves as a prevention of possible relapse (re-development) of the disease. Patients are usually sent home the same day after surgery. After 12 days, the doctor removes the stitches from the hand wound. For 3 weeks, the arm is fixed with a plaster (removable) bandage. Afterwards, rehabilitation treatment of Dupuytren's contracture is carried out. Specialists prescribe physiotherapeutic procedures, gymnastics, hand and forearm massage to the patient. 1.5 - 2 months after the operation, the hand function is restored and the ability to work returns.
Nikitin Alexander Vladimirovich
Traumatologist-orthopedist "SM-Clinic"
“Dupuytren's contracture is a hereditary disease manifested by a vicious position of the fingers. They are bent inside the palm, it is impossible to straighten them completely. Modern treatment methods make it possible to solve this problem in one visit.”
In total, since 1969, 120 patients aged 60 to 75 years have been operated on. Of these, there were 6 women and 114 men (95%). The duration of the disease ranged from 3 to 10 years. According to the prevalence of the dystrophic process, the palmar-digital localization was most often observed (70%), less often - palmar (20%) and digital (10%). Both hands were affected in 80% of patients. Typically, the process of degeneration of the palmar aponervosis began on the right hand (65%), and then moved to the left. In 78% of patients, flexion contracture of the fingers was localized on fingers IV-V; on the fifth finger it was 6%; on IV - 4%; on all fingers - in 2% of patients.
Surgical treatment was performed for Dupuytren's contractures grade 11-111. 86 patients were operated on the right hand and fingers, and 64 patients were operated on the left hand. In case of disease of both hands, first of all, they operated on the side where the pathological process was more pronounced, and only after the patient could serve himself with this hand, they operated on the other hand.
Indications for surgery were:
1) degree II-III finger contractures with impaired hand function, 2) relapses of the disease with impaired hand and finger function, 3) the patient’s desire to care for himself in everyday life.
Contraindications:
a) involutive dementia, inappropriate behavior, b) exacerbation of concomitant diseases (coronary disease, diabetes mellitus, hypertension, etc.), c) peripheral circulatory disorders with pronounced trophic disorders, d) the presence of infected wounds on the hand and fingers.
Before the operation, patients were consulted by a therapist, a neurologist, an anesthesiologist, and, if necessary, other specialists. The brush and fingers were thoroughly washed with warm water and soap, and the nails were trimmed. On the eve of the operation, the hand was treated with iodopirone and wrapped in a sterile diaper. In 87% of cases, the operation was performed under general anesthesia at the level of the wrist joint with the addition of local infiltration anesthesia. In unbalanced patients, a combination of intravenous anesthesia and conduction anesthesia was used.
At the initial stage of mastering the techniques, we performed operations with preliminary application of a tourniquet to the middle third of the forearm. However, after removal of the tourniquet, severe bleeding from the soft tissues, swelling and severe pain were noted. Taking into account these factors, as well as the presence of age-related involutive changes and concomitant diseases, for the last 30 years we have been operating without applying a tourniquet. To bleed the surgical field, we perform infiltration anesthesia of the hand and fingers with a 0.5% solution of novocaine up to 100 ml. The combination of conduction anesthesia with local one provides good pain relief, hemostasis and a more favorable postoperative course.
Features of the surgical intervention technique:
Slightly curved arcuate incisions were made on the hand above the projection of dense nodes and cords. The skin was separated, and then the palmar aponeurosis was excised from the tendons, neurovascular bundles and muscles. Strands and nodes on the fingers were excised from separate incisions along the anterolateral surface. Most often they were localized on the 4th and 5th fingers.
In patients with severe arthrogenic contractures in the proximal interphalangeal joints, capsulotomy was performed. On the operating table, full straightening of the hand and fingers was achieved.
Subcutaneous and percutaneous dissection of cords constricting the fingers and hand was performed in persons with decompensation of concomitant diseases. Subsequently, a plaster splint was applied in a position of moderate extension of the fingers and hand. 3-4 days after the operation, the splint was removed for active and passive development of movements, in order to restore the function of the fingers and hand and the ability to self-service. Treatment using the above method was carried out in 7 patients.
In the postoperative period, a plaster splint was placed on the hand and fingers in a position of slight flexion. To relieve pain, analgesics were prescribed, and to relieve swelling of the hand, the hand was placed in an elevated position with dosed local hypothermia. Dressings were performed daily for the first 3-4 days, and then every other day. From the fourth day, UHF therapy and physical therapy were prescribed. Passive movements in the fingers began from 2-3 days after surgery, active development was allowed from the 7th day. The stitches were removed after 2 weeks. As the wounds on the hand and fingers healed, the volume and strength of movements increased. During the day, the splint was removed 3-4 times for physical therapy exercises. In order to prevent flexion contracture in severe forms of contracture, “night” immobilization was carried out for up to 2 months. To restore vascular tone, starting from week 5, paraffin applications, ultrasound with hydrocortisone, warm and cold baths were prescribed, and to restore muscle tone, electrical stimulation of muscles and manual massage were performed.
Existing methods of surgical treatment of Dupuytren's contracture are conventionally divided into radical and palliative. This is due to the fact that it is technically impossible to remove the entire palmar aponeurosis, which causes relapses of the disease in 7.0-37.8% of cases. An analysis of the complications that occurred showed that in 7% of patients, the skin flaps separated during surgery were painful. They had a bluish color, swelling and a sharp decrease in sensitivity lasted for 2-3 weeks. In 2% of patients, marginal skin necrosis developed, requiring necrectomy with a positive treatment outcome.
To eliminate cicatricial flexion contracture of the fingers, which was noted in 5 patients, redressal was carried out with fixation with staged plaster splints, exercise therapy, massage and thermal procedures. Neuritis of the digital branches of the median and ulnar nerves was noted in 3% of patients. After neurotropic and physiotherapeutic treatment, these complications were eliminated.
Subcutaneous hematoma in the early postoperative period was diagnosed in 6% of patients. To remove the hematoma, during the ligation process, the skin suture was removed and the hematoma was carefully emptied. The wound was washed with hydrogen peroxide and furacillin. On days 2-3, tightly adapted wound edges thereby eliminated the tissue defect and contributed to the primary healing of the postoperative wound. Long-term results were assessed no earlier than 6 months. The majority of operated patients - 96 people - obtained good results, 16 - satisfactory and 8 - unsatisfactory.
The outcomes of surgical treatment depend on the severity and duration of the disease, surgical technique and postoperative rehabilitation. In undisciplined patients prone to alcoholism and with pronounced involutive changes in the central nervous system, unsatisfactory results were generally obtained.
Disease treatment results
The photograph of patient P. shows the long-term result of surgical treatment of Dupuytren's contracture of both hands. 9 years have passed since the operation on the right hand, and 7 years on the left hand (Fig. 3).
Fig.3. Long-term result of surgical treatment of both hands with complete restoration of function, patient P. (own observation). Finger movements are fully preserved. No re-formation of scars is observed (Fig. 4).
Fig.4. Long-term result of surgical treatment of Dupuytren's contracture, patient P. (own observation).
Surgery for Dupuytren's contracture is an effective treatment that restores ability to work and significantly improves the patient's quality of life.
Author of the article:
Alexander Vladimirovich Nikitin, operating traumatologist at SM-Clinic
2. Clinical manifestations and mechanism of development of Dupuytren’s contracture
Dysfunction of the fingers develops due to changes in the subcutaneous connective tissue. It gradually degenerates, being replaced by scar tissue that is unable to function adequately.
In this case, the following picture is observed. The hand continues to freely extend and bend, but the fingers lose this ability.
The pathology may be accompanied by loss of sensitivity in some areas. Over time, the palm becomes deformed. All these changes contribute to loss of finger control, as well as, often, chronic pain in the hand.
There are three stages in the development of pathology:
- at the first stage, only cords and nodes in the tissues of the palm are visible;
- the second stage is assigned when scarring leads to such contraction of the fingers that fixes them in a position perpendicular to the plane of the palm, but they are still capable of performing some functions;
- in the third stage, finger mobility and skin sensitivity are completely lost, the skin becomes dry and may crack.
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3. Diagnosis of Dupuytren's contracture
A diagnosis of Dupuytren's contracture can be made preliminary based on external manifestations, functional disorders and patient complaints.
In the early stages, nodes and cords in the palmar fascia are detected by palpation. More severe development of the disease is characterized by changes in the position and geometry of the fingers, as well as disturbances of the skin and sensitivity. Nodes and cords spread from the palms to the phalanges of the affected fingers.
A clarifying method for diagnosing Dupuytren's contracture is radiography. It allows you to exclude tumor diseases and inflammatory pathology of the tendons.
The course of the disease is very individual. Sometimes at a certain stage the contracture remains for years, in other cases it progresses very quickly and even leads to cicatricial fusion of the joints in the affected areas.
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