Dupuytren's

Question 1

Who is Dupuytren’s named after?

Answer 1

• French anatomist and military surgeon Dr. Guillaume Dupuytren
• Identified the condition in Scottish clans and orginally described it in 1831
• Originally brought to Northern Europe by the Vikings
• There is a genetic link: genetic enzyme produces extra collagen in fascia

Question 2

What tissues are affected in a Dupuytren’s Contracture?

Answer 2

• Longitudinal fibers of the palmer fascia
• • Palmer aponeurosis
• • Tendon of palmaris longus
• Usually begins at the A1 pulley

Question 3

What are other forms of Dupuytren’s?

Answer 3

• Ledderhose Disease: can occur in the feet
• Peyronie’s Disease: can occur in male genitalia
• Can be triggered by trauma including fractures, surgery, sprain, etc.
• Can happen from a very small injury like jamming your finger

Question 4

What are two characteristics of a Dupuytren’s Contracture?

Answer 4

• Nodules
• Cords
• Blood flow and skin integrity are affected

Question 5

What can Dupuytren’s Contracture be mistaken for?

Answer 5

• Trigger finger in the early stages because of tenderness at the MPJ. The pulleys are deep
• Dupuytren’s is a disease of shallow tissue and is a contracture of the palmer fascia, not a mechanical friction problem

Question 6

How are occupations impaired by Dupuytren’s?

Answer 6

• Difficulty grasping objects such as a comb, brush, steering wheel, cup, handles, tools, etc.
• Fingers can get hung up on objects
• Hard to load hand and hang on to small objects like change
• Advance stages can be painful
• Golfer’s can develop Dupuytren’s
• To work on hand loading: take beads and try to add as many beads to the affected hand

Question 7

What is OTs role in treating Dupuytren’s?

Answer 7

• A conservative role
• Educate patient about diagnosis
• Teach hand flattening stretch on table (hold for 20 seconds/5 times a day)
• Create night splint
• Provide joint protection strategies
• Try to prevent inflammation
• OTs want to help prevent patient from having surgery
• Dupuytren’s affects both flexion and extension because the tissues cannot move freely
• PIPs can also develop contractures and it is commonly seen in the ring finger and little finger
• Unlike joint contracture, Dupuytren’s is not reversible. OTs can only prevent further shortening

Question 8

What are injections commonly used with Dupuytren’s?

Answer 8

• Xiaflex injections: collagenase clostrodium histolyticum (new medication within the last 7 years). Made out of Gangrene bacteria and it attacks the fascia
• The doctor injects collagenase and then the next day the doctor breaks up the fascia (mechanical release). Then the patient receives therapy
• Can be a very aggressive treatment and it can cause tendons to rupture, bleeding, bruising, and skin rips

Question 9

What is a needle aponeurotomy?

Answer 9

• Release of fascia using a needle
• Performed under local anesthesia
• There is risk of injuring the tendon

The diseased tissue can also be excised during surgery

Question 10

What can OTs do to help patient post-op?

Answer 10

• Dressing changes
• Wound care
• Splinting: hand-based splint. Do not want to put structures in full extension. The tissue needs to lengthen slowly over a two week period to get MCP joints straight
• Scar massage and edema control
• Desensitization: graded sensory training with rice, macaroni, marbles, etc.
• AROM (directly following surgery)
• Gentle strengthening can take place once wound is fully healed (usually around 3-4 weeks)

Question 11

What are ganglion cysts?

Answer 11

• Ganglion cysts are common lumps within the hand and wrist that occur adjacent to joints or tendons
• The most common locations are the top of the wrist, the palm side of the wrist (FCR and FCU), the base of the finger on the palm side, and the top of the end joint of the finger (DIP joint)
• They are typically fluid filled or they can be made of fat (lipoma)

Question 12

What is the most common joint ganglion?

Answer 12

• Scapholunate joint
• Develops from repetitive or forced trauma)
• Caused by a small tear in the capsule that then fills up with fluid
• The stalk can wrap around nerves and cause compression symptoms
• Similar symptoms to CTS. To rule out CTS, have patient flex wrist to see if a ganglion surfaces

Question 13

What causes ganglion cysts?

Answer 13

• Unknown but could be from joint and tendon irritation or mechanical changes
• They occur in patients of all ages
• They may change in size or disappear completely, and they may or may not be painful
• They are not cancerous and will not spread to other areas

Question 14

How is a ganglion cyst treated?

Answer 14

• Observation and waiting
• Needle aspiration followed by compression but reoccurrence is common
• Aspiration and cortisone
• Splinting to rest the irritated tissue