Dupuytren's contracture is a condition in which one or more fingers bend permanently in a bent position. It usually starts as a small hard nodule just under the skin of the palm of the hand. This then worsens over time until the fingers can no longer be straightened out. While usually does not feel pain or itching. The finger followed by the small and middle fingers is most often affected. This can disrupt preparing food, writing, and other activities.
The cause is unknown. Risk factors include family history, alcoholism, smoking, thyroid problems, liver disease, diabetes, previous hand trauma, and epilepsy. The underlying mechanism involves the formation of abnormal connective tissue in the palmar fascia. Diagnosis is usually based on symptoms.
Initial treatment is usually by steroid injections to the affected area and physical therapy. Among those who deteriorate, injections or clostridial collagenase surgery can be tried. While radiation therapy is used to treat this condition, the evidence for this use is poor. This condition can relapse despite being treated.
Dupuytren is most common in men over the age of 50. Most affects white people and is rare among Asians and Africans. In the United States about 5% of people are affected at some point in time, while in Norway about 30% of men aged over 60 years have the condition. In the UK, about 20% of people over 65 have some form of disease. Named after Guillaume Dupuytren, who first described the underlying mechanism in 1833.
Video Dupuytren's contracture
Signs and symptoms
Usually, Dupuytren contractures first present as a thickening or nodule in the palm of the hand, which can initially be with or without pain. Later in the disease process, there is an increase in the loss of various movements of the affected fingers. The initial sign of contracture is the triangular "wrinkling" of the skin of the palm as it passes through the flexor tendon just before the flexor flexion of the finger, at the metacarpophalangeal joint (MCP). Generally, straps or contractures do not cause pain, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring finger; thumb and index finger are much less affected. The disease begins in the palm of the hand and moves toward the fingers, with the metacarpophalangeal joint (MCP) affected before the proximal interphalangeal (PIP) joint.
In Dupuytren contracture, the palmar fascia in the hand becomes abnormally thick, which can cause the fingers to bend and can damage the function of the finger. The main function of the palmar fascia is to increase the strength of the grip; thus, over time, Dupuytren contractures reduce a person's ability to hold objects. People may report pain, pain and itching with contractions. Typically, palmar fascia consists of type I collagen, but in Dupuytren patients, collagen is transformed into type III collagen, which is significantly thicker than type I collagen.
Related conditions
People with severe involvement often show a lump on the back of their finger joints (called "Garrod's pad", "finger pads", or "dorsal Dupuytren nodules") and bumps in the arch of the foot (Plantar fibromatosis or Ledderhose disease). In severe cases, the area where the palms meet with the wrist may develop a lump. Severe Dupuytren disease may also be associated with frozen shoulder (shoulder capsulitis shoulder), Peyronie's disease in the penis, increased risk of some cancers, and the risk of premature death, but more research is needed to clarify this relationship.
Maps Dupuytren's contracture
Risk factors
Dupuytren's contracture is a disease that is not specific but mainly affects:
Unable to modify
- People of Scandinavian or northern European descent, have been called "Viking disease", although it is also widespread in some Mediterranean countries (eg, Spain and Bosnia). Dupuytren is unusual among ethnic groups such as China and African.
- Men rather than women; men are more likely to develop the condition)
- People over 50 years old; likely to develop Dupuytren disease with age
- People with a family history (60% to 70% of those suffering have a genetic predisposition to Dupuytren contractures)
Modifiable
- Smokers, especially those who smoke 25 or more cigarettes a day
- Thin people (ie those with lower body mass index than average)
- Workers manual
- Alcoholic
Other conditions
- People with fasting blood glucose levels are higher than average
- People with previous hand injuries
- People with Ledderhose disease (plantar fibromatosis)
- People with epilepsy (probably because of anti-seizure medications)
- People with diabetes mellitus
- People with HIV
In one study, those with stage 2 disease were found to have a slightly increased risk of death, especially from cancer.
Diagnosis
Type
According to specialist Dr. Charles Eaton of Dupuytren, there may be three types of Dupuytren's disease:
- Type 1: A very aggressive form of disease is found in only 3% of people with Dupuytren, which can affect men under 50 with a family history of Dupuytren. Often associated with other symptoms such as finger pads and Ledderhose disease. This species is sometimes known as Dupuytren diathesis.
- Type 2: A more normal type of Dupuytren disease, usually found in the palms of the hands only, and which generally begins above the age of 50 years. According to Dr Eaton, this type can be made more severe by other factors such as diabetes or severe rough work.
- Type 3: The mild form of Dupuytren is common among diabetics or who may also be caused by certain drugs such as anti-convulsants taken by people with epilepsy. This type does not lead to full contracture of the fingers and may not be inherited.
Treatment
Treatment is indicated when the so-called positive test on the table. With this test, the man put his hand on the table. If the hand is completely flat on the table, the test is considered negative. If the hand can not be fully placed on the table, leaving the space between the table and the hand part as big as the ballpoint diameter, the test is considered positive and surgery or other treatments may be indicated. In addition, the finger joints can become stiff and fixed.
Treatment involves one or more different treatments with multiple hands requiring repeated treatment.
The main categories listed by the Dupuytren International Society in order of disease stage are radiation therapy, needle aponeurotomy (NA), collagenase injections and hand surgery.
The most effective needle aponeurotomy for Stages I and II, covering 6-90 degrees of finger deformation. However, it is also used at other stages.
Collagenase injection is also most effective for Stages I and II. However, it is also used at other stages.
Effective hand operation in Phase I - Phase IV.
Surgery
On June 12, 1831, Dupuytren performed a surgical procedure on a person with a contracture of the 4th and 5th digit who had previously been told by another surgeon that the only cure was to cut the flexor tendon. He described conditions and operations at The Lancet in 1834 after presenting it in 1833 and posthumously in 1836 in a French publication by HÃÆ'Â'tel-Dieu de Paris. The procedure he describes is a minimally invasive needle procedure.
Because of the high recurrence rate, new surgical techniques are introduced, such as fasciectomy and then dermofasciectomy. Most of the diseased tissue is removed by this procedure. High relapse rate. For some individuals, the partial insertion of "cable K" into the DIP or PIP joint of the affected digit for a period of at least 21 days to unite the joints is the only way to stop the progression of the disease. After the lifting of the cable, the connection is fixed to flexion, which is considered better for fusion on the extension.
In extreme cases, finger amputations may be necessary for severe or recurrent cases or after surgical complications.
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Limited/selective physiectomy removes pathological tissue, and is a common approach.
During the procedure, the person is under a regional or general anesthesia. A surgical nipple prevents blood flow to the extremities. The skin often opens with a zigzag incision but a straight incision with or without Z-plasty is also described and can reduce damage to the neurovascular bundle. All the aching ropes and fascia are cut off. Excision must be very appropriate to save the neurovascular collection. Since not all diseased tissues look macroscopic, complete excision is uncertain. A review of 20 years of surgical complications associated with fasciectomy showed that major complications occurred in 15.7% of cases, including digital nerve injury (3.4%), digital artery injury (2%), infection (2.4%), hematoma (2.1%), and complex regional pain syndrome (5.5%), in addition to minor complications including painful flare reactions in 9.9% of cases and wound healing complications in 22.9% of cases. After the tissue is removed, the surgeon closes the incision. In the case of skin deficiency, the transverse portion of the zig-zag incision is left open. Stitches removed 10 days after surgery.
After surgery, the hands are bandaged with lightweight compressive bandages for one week. People start bending and extending their fingers as soon as the anesthesia is over. Hand therapy is often recommended. About 6 weeks after surgery people can fully use their hands.
The mean recurrence rate was 39% after fasciectomy after an average interval of about 4 years.
Extensive phatectomy
Flexectomy is limited/selective under local anesthesia (LA) with epinephrine but no tourniquet is possible. In 2005, Denkler explained his technique.
Dermofasciectomy
Dermofasciectomy is a surgical procedure that is primarily used in recurrence and for people with high probability of recurrence of Dupuytren contractures. Similar to the finite fasciectomy, dermofasciectomy removes the diseased membrane, fascia, and skin on it. The skin is then covered with a skin graft, usually full of thickness, which consists of the epidermis and the entire dermis. In most cases, the graft is taken from the antecubital fossa (the skin fold on the elbow joint) or the inner side of the upper arm. This place is selected, because the skin color best matches the color of the skin of the palm. The skin on the inside of the upper arm is thin and has enough skin to supply a full thickness graft. Donor sites can be closed with direct stitches.
The graft is sewn to the skin around the wound. For a week the hands are covered with sauce. Hands and arms lifted with sling. Dressing is then removed and careful mobilization can begin, gradually increasing in intensity. Following this procedure, the recurrence of the disease may be low but the extent of surgery and complications may be high.
Segmental fascectomy with/without cellulose
Segmental facsimation involves the excision parts (s) of the contracted cable so that it disappears or no longer contracts with the fingers. It's less invasive than the limited fasciectomy, because not all diseased tissue is cut and the skin incision is smaller.
The person is placed under regional anesthesia and surgical tourniquet is used. The skin opens with a small curved incision over the diseased tissue. If necessary, incisions are made on the fingers. Pieces of rope and fascia about one centimeter cut. The rope is placed below the maximum voltage when cut. Skalpel is used to separate the network. The surgeon keeps removing the small parts until the finger can widen completely. The person is encouraged to start moving his hand the day after surgery. They use extension splints for two to three weeks, except during physical therapy.
The same procedure is used in the segmental fasciectomy with cellulose implants. After careful excision and hemostasis, cellulose implants are placed in one layer between the remaining portions of the umbilical cord.
After surgery the person was wearing a light pressure sauce for four days, followed by a splint extension. Splint is worn continuously during the night for eight weeks. During the first weeks after surgery, splints can be worn during the day.
Less invasive treatment
Research has been conducted for release of percutanes, extensive percutaneous aponeurotomy with lipograft and collagenase. This treatment is promising.
Peripheral needle physiotomy
Needle aponeurotomy is a minimally invasive technique in which the rope is attenuated by insertion and small needle manipulation. The cord is cut as much as possible as high as possible on the palms and fingers, depending on the location and extent of the disease, using a 25-gauge needle mounted on a 10ml syringe. Once attenuated, the offending cable can be fastened by putting the strain on the finger and pulling the finger straight. After treatment, a small sauce is applied for 24 hours, after which people can use their hands normally. No splint or physiotherapy is given.
The advantage of needle aponeurotomy is minimal intervention without incision (done at the office with local anesthesia) and very quickly returns to normal activity without the need for rehabilitation, but the nodules can continue growth. One study reported greater postoperative profits at the MCP-joint rate than at the IP-joint level and found 24% relapse rate; rare complications. Needle aponeurotomy can be performed on the highly bent fingers (stage IV), and not just in the early stages. A 2003 study showed an 85% recurrence rate after 5 years.
A comprehensive review of the results of an aponeurotomy needle at 1,013 fingers is done by Gary M. Pess, MD, Rebecca Pess, DPT and Rachel Pess, PsyD and published in the Journal of Hand Surgery April 2012. The minimum followup is 3 years. Metacarpophalangeal joint (MP) contraction was corrected at an average of 99% and proximal interphalangeal joint (PIP) contraction averaged 89% immediately after the procedure. At the final follow-up, 72% correction was maintained for the MP joint and 31% for the PIP joint. The difference between the final correction for MP versus PIP joints was statistically significant. When comparisons were made between people 55 and older than under 55, there was a statistically significant difference in MP and PIP joints, with larger corrections maintained in the older group. Gender differences are not statistically significant. Needle aponeurotomy successfully correction to 5 Â ° or less post-procedure promptly on 98% (791) MP joints and 67% (350) PIP joints. Recurrence 20 Â ° or less than the original post-procedure correction level in 80% (646) MP joints and 35% (183) of the PIP joint. Complications are rare except skin tear, which occurs in 3.4% (34) digits. This study shows that NA is a safe procedure that can be performed in an outpatient setting. The rate of complications is low, but recurrences are common in younger people and for PIP contractures.
Broad percutaneous apotheosis and lipogram
The technique introduced in 2011 is an extensive percutaneous aponeurotomy with lipografting. This procedure also uses a needle to cut the rope. The difference with percutaneous percussive fasciotomy is that the umbilical cord is cut in many places. The umbilical cord is also separated from the skin to make a place for lipograft taken from the abdomen or ipsilateral side. This technique shortens the recovery time. Fat graft produces supple skin.
Before the aponeurotomy, liposuction is done to the abdomen and the ipsilateral side to collect lipograft. Treatment may be performed under regional or general anesthesia. The numbers are placed under maximum extension tension using the company's lead hand retractor. The surgeon made several palmar puncture wounds with a small incision. Tension on the rope is very important, because the tight binding tape is very vulnerable to cut and tear by a small incision, while relatively loose neurovascular structures are not disturbed. After the rope is completely cut and separated from the skin, the lipograft is injected under the skin. A total of about 5 to 10 ml is injected per ray.
After treatment, the person uses an extension splint for 5 to 7 days. After that the person returns to normal activity and is advised to use the night splint up to 20 weeks.
Collagenase
Clostridial collagenase injection has been found to be more effective than placebo. The cable is attenuated by injection of a small amount of the collagenase enzyme, which breaks the peptide bond in collagen.
Treatment with different collagenases for MCP joints and PIP joints. In contracting the joints MCP needles should be placed at the point of the maximum arc of a palpable strap.
The needle is placed vertically on the bowstring. Collagenase is distributed at three points of injection. For PIP, the needle should be placed no more than 4 mm distal to the palmar digital folds at a depth of 2-3 mm. Injection for PIP consists of one injection filled with 0.58 mg CCH 0.20 ml. The needle should be placed horizontally to the cable and also use a 3-point distribution. After the injection, the person's hands are wrapped in large gauze and must be raised for the rest of the day. After 24 hours, the person returns to a passive digital extension to disconnect the cord. Medium pressure for 10-20 seconds hurts the cord.
After treatment with collagenase, one should use the night splint and perform flexion exercises/digital extensions several times per day for 4 months.
In February 2010, the US Food and Drug Administration (FDA) approved a collagenase injection extracted from Clostridium histolyticum for the treatment of Dupuytren contracture.
Radiation therapy
Radiation therapy has been used mostly for early stage diseases, but is not proven. The evidence to support its use in 2017, however, is poor; attempts to gather complicated evidence because of poor understanding of how conditions evolve over time. That's just seen in the initial illness.
Alternative medicine
Several alternative therapies such as vitamin E treatment have been studied, even without a control group. Most doctors do not value the treatment. None of these treatments stop or cure the condition permanently.
Laser treatments (using red and infrared at low power) are informally discussed in 2013 at the International Dupuytren Society forum, at which time little or no formal evaluation of the techniques has been completed.
Only anecdotal evidence supports other compounds such as vitamin E.
Prognosis
Dupuytren disease has a high recurrence rate, especially when a person has been called Dupuytren diathesis. The term diathesis relates to certain features of Dupuytren's disease and shows the aggressive course of the disease.
The presence of all new Dupuytren diathesis factors increased the risk of recurrent Dupuytren disease by 71% compared with a baseline risk of 23% in people who did not have a factor. In another study the prognostic value of diathesis was evaluated. They conclude that the presence of diathesis can predict recurrence and expansion. The scoring system was made to evaluate the risk of recurrence and extension evaluating the following values: bilateral hand involvement, finger pink operation, early onset of the disease, plantar fibrosis, finger pads and radial side involvement.
Minimally invasive therapy may precede a higher recurrence rate. Recurrence has no consensus definition. Furthermore, different standards and sizes follow from various definitions.
Postoperative care
Postoperative care involves hand and splinting therapy. Hand therapy is prescribed to optimize post-operative function and to prevent joint stiffness.
In addition to hand therapy, many surgeons recommend the use of static or dynamic splints after surgery to maintain finger mobility. Splint is used to extend strain to the healing tissues and prevent flexion contractures. Although splinting is a widely used post-operative intervention, the evidence of its effectiveness is limited, causing variation in the splinting approach. Most surgeons use clinical experience to decide whether to splint. The benefits mentioned include the maintenance of finger extensions and the prevention of new flexion contractures. The disadvantages mentioned include joint stiffness, prolonged pain, discomfort, then reduced function and edema.
The third approach emphasizes self-training and early stretching.
Famous cases
- Bill Frindall, who has a finger amputated.
- Margaret Thatcher
- Misha Dichter
- Prince Joachim of Denmark
- Ronald Reagan
- Bill Nighy
See also
Knuckle Bearing
References
External links
Source of the article : Wikipedia
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