Dupuytren’s Contracture

Question 1

What is dupuytren’s contracture

Answer 1

-a contracture of the palmar fascia, resulting in a flexion deformity of the fingers

Question 2

Relevant Information

Answer 2

-MCP and IP joints of the 4th and 5th digits are most frequently affected
-due to contracture, patient with this condition is unable to extend affected digits voluntarily or by force
-palmar fascia, skin, subcutaneous tissue, including cushioning fat lobules are relatively fixed together that does not appear in any other part of the body except the plantar surface of the foot
-purpose of this fixation appears to be to absorb pressure and to limit mobility of skin
-3 fibre directions to the palmar fascia: longitudinal, transverse and vertical; these are necessary to counteract forces applied to the palm of the hand; longitudinal and transverse counteract forces acting on the palm when hand is gripping something
-longitudinal fibres are most superficial and run from Palmaris longus tendon to skin midway between proximal and distal palmar creases; some fibres also continue to spiral around MCP joints and insert on the lateral portions of the phalanges; function to prevent longitudinal shear forces-control rotational forces on the palm (gripping a baseball bat)
-transverse fibres are deeper layer of palmar fascia; run from anterior portion of flexor tendon sheaths to thenar and hypothenar eminences; stabilize against transverse forces (sliding down firefighters ‘pole)
-vertical fibres have a slightly different function; these fibres run from skin down to tendon sheaths and the metacarpal bones; function to bind layers of palmar fascia to skin & bones of hand
-Dupuytren’s contracture begins with a shortening and fibrosing of some of the longitudinal fibre bundles which ascend into the palmar skin; when fibres that spiral around phalanges become involved, joint flexion contractures develop; more frequently bilateral than unilateral
-Palmaris longus functions to flex the wrist and is the only muscle that tenses the palmar fascia; it has no antagonist, perhaps predisposing it to flexion deformity

-it is thought that a proliferation of fibroblasts in the palmar fascia produces new collagen which forms into nodules

Intrinsic theory: the shortening occurs due to changes within the palmar fascia itself, leading to the nodules and then the contractured bands of tissue

Extrinsic theory: the shortening occurs due to changes in the tissue between the dermis and the palmar fascia; the nodules are found subcutaneously, anterior to the palmar fascia

Question 3

Causes

Answer 3

-idiopathic in nature
-hereditary: inheritance of a dominant gene-appears to be a factor
-association between Dupuytren’s contracture and epilepsy, prolonged immobilization of the hand alcoholism and possibly diabetes
-believed recurrent micro trauma to the hand is NOT primary cause
-other contributing factors: hyperkyphosis, TOS, leading to reduced circulation, TP referral and reduced tissue health in a patient’s arm

Question 4

Symptom Picture

Answer 4

-condition is often bilateral
initially palmar fascia becomes tender, thickened & nodular; may be small dimple or pucker just distal to the palmar crease, visible when the MCP joints are extended & IP joints are flexed
-as condition progresses, palmar fascia contracts, drawing affected digits into flexion; affected
-progression may stop at any stage (n: —> cold)
flexor tendons appear thickened and raised; skin over them becomes ridged
-decrease in local circulation occurs due to dense tissue of contractures and fibrous bands
-active free extension of affected IP joints is not possible due to the flexion contractures

Question 5

Health History Questions

Answer 5

How is the patient’s general health? Does the patient have any associated conditions, such as epilepsy or diabetes?
Does anyone in the patient’s family have this condition?
When was the onset? If onset was more recent, treatment may take less time and be more effective.
What is the type and location of the pain? May be described as tenderness/achiness in the palm.
What activity aggravates the condition?

Question 6

Observations

Answer 6

-postural scan will indicate possible contributing factors, such as hyperkyphosis and a head forward posture
-palmar aspect of the affected hand is assessed for dimpling of the palmar skin immediately distal to the palmar crease, ridging of the palmar skin and usually fixing of the 4th and 5th fingers in flexion at the MCP or IP joints

Question 7

Palpation

Answer 7

-discrete, palpable nodules in the palmar fascia and possibly over the proximal phalange are indicators; thickening of the palmar skin is evident
-tenderness present around the nodules & contracture & diffuse tenderness is present in the palm
-increased tone in the cervical muscles, rotator cuff and flexor muscles of the wrist may be present.
-to differentiate whether the palmar tenderness is a result of a TP in Palmaris longus or the contracture itself, the muscle is specifically palpated
-coolness due to ischemia is possible in the palm and affected fingers

Question 8

Testing

Answer 8

-AROM of the C spine, shoulder girdle, elbow, wrist and each of the joints of the affected digits is performed; patient will be unable to fully extend the affected wrist and fingers

-pain on extension may be present

• PROM of affected wrist and each of the joints of affected fingers will reveal decreased extension, with a leathery end feel and possible pain on attempted forced extension (n: do 1 joint at the time)

-MRT reveals possible reduced strength of the wrist and finger flexors and extensors of the hand

Question 9

Contraindications

Answer 9

• friction techniques are CI’d if taking anti-inflammatories

-following surgical treatment, with patient’s permission, patient’s physician and PT should be contacted before specific massage treatment to the wrist and hand occurs

Question 10

Treatment Plan

Answer 10

-hydrotherapy: pre-treatment paraffin wax
-context of relaxation massage
-reduce hypertonicity and trigger points in muscles of upper back and rotator cuff, cervical spine, pecs and unaffected arm
-flexor and extensors of the affected arm are treated
-wrist, palm and intrinsic hand muscles are treated
-fascial techniques to treat the contractured tissue
-adhesion and thickening in palmar fascia and around the tendons are treated using frictions, followed by ice
-maintain or increase ROM with massage, fascial techniques and frictions interspersed with passive relaxed extension, progressing to slow passive forced extension of each of the affected joints; sufficient pressure is used to stretch the contractures without tearing the tissue (n: each joint)
-passive relaxed extension of the wrist and elbow
-increase local circulation to improve tissue health with contrast hydrotherapy

Question 11

Self-Care

Answer 11

-maintain tissue health with paraffin bath followed by self-massage
-if possible, restore ROM with focus of stretching extension of wrist, MCP and IP joints