Keys of Dupuytren Disease. Anatomy and Treatment

American Society for Surgery of the Hand

A perfect knowledge of palmar structures of the hand will determine the proper management of that disease.

Anatomy of Palmar Hand. Key of Dupuytren Management.

We consider important to start with a brief review of the Palmar Fascia. From Proximal to distal we have:

1.Palmar Aponeurosis: it originates at the wrist close to Palmaris Longus tendon. It diverges from the wrist into:

–Pretendinous Bands, longitudinal strips that course toward the fingers. In a Sagital plane it divides into: Superficial fibers, Intermediate-Depth Fibers (which bifurcates into 2 separate strips; Spiral bands and Lateral digital sheet) and Deepest Fibers (related to metacarpal joint capsule and tendon flexor shealth).

– Two sets of transverse fibers in the palm; Superficial Transverse palmar Ligament and Natatory Ligament.

Within hand fingers we include Digital Fascia, which includes Lateral Digital Fascia, that projects into: grayson Ligaments (volar side) and Cleland Ligaments (dorsal side). Those ligaments has a protective function in neurovascular bundle.

Progression of Dupuytren´s Disease

Most of the time, Dupuytren´s Disease usually begins as “nodules” which progressively develop into cords. 

That evolution is described into the bibliography divided in three stages:

1. Proliferative Phase.

In this stage, nodules start to appear in fatty and superficial areas predominantly. Those nodules are gradually filled of myofibroblasts in a dense and chaotic organization, which produces ischemia.

Also cytokines, transforming Growth Factor (TGF)-b1 and free radicals are produced in those bumps, resulting in Type III Collagen production.

2. Involutional Phase.

In that stage, nodules contraction start caused by TFG-b1 action, which results in cords production. Also collagen maturation colaborates in cords appearance.

While Dupuytren progress, Colagenase begins to interact.

3. Residual Phase.

In that Dupuyytren stage, cells stop their activity and shortening is definitively established.

Where Dupuytren Nodules usually appear?

Most of the time, nodules grow from normal fascial structures, and present as an abnormal thickening of hand fascia. Typically between superficial Fascia structures and skin.

Dupuytren´s Contracture follows the multiple anatomical structures of palmar fascia. That´s why is so important to perfectly know those structures for a correct management.

Usually start with that thickening at the Pretendinous Bands and Natatory Ligament, being 4th finger the most common. Then, Digital fascia starts to be affected, and progressively Fingers motion will be limited.

How often Dupuytren Disease appears?

Global datas of prevalence are different, vary from 3-42% depending of the country. It seems to be more prevalent in North Europe and in light-skinned people.

For example, Dupuytren Disease reaches 30% in Norwegian population over 60 years old. In Spain, datas are progressively increasing every year.

Dupuytren Risk Factors

Some authors propose an autosomal dominant hereditary factor as predisposing to Dupuytren appearance.

Also, other factors are proposed in bibliography:

1. Age:

Risk of Dupuytren increase with age. The mean of appearance is 49 years old with family history. That´s why:

A) The older they are the more likely it is that the origin comes from an enviromental factor.

B) The younger they are, more likely it is that the origin comes from an genetic factor.

2. Gender

Women´s appearance of Dupuytren is lesser than in men, with ratio from 7:1 to 15:1 recorded.

3. Trauma in Hand, Manufacturing Work.

Injuries, works with hand and fingers implications, infections, previous surgery or exposure to vibration have been suggested as predisposing factors for Dupuytren occurrence.

Also some studies relates climbing practice and Dupuytren appearance.

4. Alcohol and Tobacco cosumption.

That relationship is not actually clear and is a controversial issue in published articles. We cannot conclude that Dupuytren has correlation with that habits.

What we can really relate to the tobacco comsumption are complications post-surgery. A greater probability and severity of suffering from problems after a surgical management has been associated in different articles.

5. HIV

Lack of robust evidence is present when author has tried to analyse the relationship with both patologies.

6. Rheumatoid Arthritis (RA)

The only condition that is inversely related with Dupuytren Disease is RA. There is a significant reduction in prevalence in these patients, suggesting a protective genetic factor.

Dupuytren Disease Treatment

When this condition causes disability in patient´s hands, surgical management is the first option. Preventive treatment through exercises, stretching or splints has not proven to be effective, although much literature has yet to be written.

One of the most common surgeries are Fasciectomies. Once surgery is finished, physiotherapy and Occupational Therapy will have an important role to recover patients:

1- Orthosis

Are often used after surgical intervention to maintain the mobility gained in fingers. It is usually recommended to wear it 24 hours a day during the first week. Then, progressively, only using it at nights.

Reviewing the literature on Dynamic Extensor Orthoses and Static Orthoses. no clear data are shown. But we can conclude:

A) We should provide orthoses to patients with rapid loss of finger extension in the early post-operative period, rather than wear it on a routinely way.

B) European experts on Hand Surgery and Hand therapy propose its use in severe cases, open surgical intervention or patients with an important preoperative contracture of Proximal Interphalangeal (PIP) Joints.

2- Exercise

Tendency of many health proffesionals after surgery is to completely inmobilize fingers, instead of progressively moving it. That promotes further shortening of joints that has been released.

Therapeutic Exercise monitored by physiotherapist, hand therapist or TO is essential in order to maximize funcionality and prevent comorbilities and shortening.

Those exercises must be individualized and prescribed by the therapist. Also, tissues response to that stimulus must be constantly monitored.

Here is an example of an exercise prescribed with ReHand App, where patient perform his treatment protocol on a tablet.

It is so important to emphasize that active exercises produce less stress in tissues than passive exercises, so it will be always recommended to start them as soon as possible in the Inflammatory and early fibroblastic stages of tissue healing.

IMPORTANT: patients affected in PIP need more recovery time after their Surgical release. Therefore, first week post surgery will begin with flexion exercises and progress in the following weeks as the surgical wound heals.

One example could be a Tendon Gliding exercise.

3- Patient Education

Every single health proffesional that conforms multidisciplinary team  promote the patient to be as active as possible in his post-operative period. Examples as explaining how to perform daily living activities protecting their scar or how to improve their exercises.

Bibliography

1. Hindocha S, Laser B. Risk Factors , Disease Associations, and Dupuytren Diathesis. Hand Clin [Internet]. 2018;34:307–14. Available from: https://doi.org/10.1016/j.hcl.2018.03.002

2. Leibovic SJ. Normal and Pathologic Anatomy of Dupuytren Disease. Hand Clin [Internet]. 2018;34:315–29. Available from: https://doi.org/10.1016/j.hcl.2018.04.001

3. Zhang AY, Kargel JS. The Basic Science of Dupuytren Disease. Hand Clin. 2018;34:301–5.

4. Turesson C. The Role of Hand Therapy in Dupuytren Disease. Hand Clin. 2018;34:395–401.

Pablo Rodríguez Sánchez-Laulhé

Physiotherapist and Health Researcher