Dupuytren ’ s Contracture: Not Just A Disease for Vikings

1. Dupuytren’s Contracture:Not Just A Disease for Vikings Presented by Michael Mangonon, DO, FACOS Atlanta Hand Specialist

2. Conflict of Interest Disclosure I have no conflicts and nothing to disclose

3. Abnormal thickening of fascia located in the palm • Tightening of the fascia can lead to Dupuytren’s Contracture • Affects 10 million Americans (30 million worldwide) • No prevention or cure • Celebrities with the disease include Ronald Reagan, Margaret Thatcher, Mitt Romney, Paul Newman, Frank Sinatra, Bill Murray, John Elway What is Dupuytren’s Disease?

4. History • Traditionally thought that disease originated in the Vikings who spread it throughout Northern Europe during their conquests • Earliest description by Felix Platter in 1680 • Named after Baron Guillaume Dupuytren who gave the defining lecture describing the disease on December 5, 1831 What is Dupuytren’s Disease?

5. Patients present with difficulty performing daily activities • placing hands in pockets, putting on gloves, shaking hands, grasping large objects, reaching into narrow spaces, cleaning hands • Usually slow progression • Without contracture there may be no treatment needed • 1 in 10 patients do not progress to contracture Progression of the Disease

6. Exact cause is unknown • Disease linked to smoking, alcohol, diabetes, nutritional deficiencies, seizure disorder medications • No evidence has linked the disease to occupation, injury, or surgery (although patients describe it anecdotally) Causes

7. Age > 40 • Men > Women • Diabetes • Family history • Can skip generations • Northern European decent • English, Irish, Scottish, French, Dutch • Scandinavian descent • Swedish, Norwegian, Finnish • When disease occurs at a younger age it tends to progress more severely Risk Factors

8. Arthritis • Tendonitis / Trigger Finger • Joint dislocation • Extensor tendon rupture Differential Diagnosis

9. Fascia • fibrous layer of tissue below the skin but superficial to the tendon in the palm and fingers • Anchors and stabilizes the palmar skin • Needed for gripping, as compared to mobile skin on the dorsum of the hand Anatomy

10. Nodules, puckering, dimpling, pitting, and cord formation in the palm • Can occur from the level of the proximal palm to the distal interphalangeal joint • Mainly affects the small and ring fingers but can affect any finger (rarely the thumb and index finger are affected) • Nodules can be sensitive to touch but usually not painful • Contractures • occur when cords thicken and shorten • Fingers are pulled into a flexed position • More commonly occurs in metacarpophalangeal joints but also seen in proximal and distal interphalangeal joints • Also present in the feet as Ledderhose Disease and in the penis as Peyronie’s Disease Signs / Symptoms

11. Visual exam • Nodules, pitting, cords • Garrod’s nodes (knuckle pads, on the dorsum of the PIP joints) • ROM testing – to determine degree of contractures and which joints are affected • Sensation testing • Table Top Test – positive when hand and fingers cannot be placed flat onto a table Physical Exam

12. X-ray • Arthritis • Joint dislocation • MRI • Soft tissue mass • Tendon pathology Testing

13. No cure for the disease • Goal of treatment is to improve contractures and increase ROM • Non-surgical • Splinting • Does not prevent progression • Steroid injection • Into painful nodules • May slow progression • Radiation • Used for prevention when nodules present without contracture • Though recent studies show rates of progression equal to or greater than no treatment Treatment Options

14. Procedures • Needle Aponeurotomy • Insert needle into cord percutaneously and use the sharp bevel to cut the cord • Achieves extension right away • Risk of injury to tendon, vessel, nerve • High recurrence rate • Enzyme Injection • Inject enzyme into cord to cause weakening of the tissue then manipulate 24-72 hours later to break and separate the cord to allow extension • Risk of allergic reaction and tendon rupture • High recurrence rate • 2nd most common treatment currently Treatment Options

15. Surgical • Fasciotomy • Incision made over cord, cord dissected and cut using knife, wound left open to heal by secondary intention • Fasciectomy • Large incision made along the length of the cord, cord dissected to protect surrounding structures, excision of as much cord and affected tissue is needed to obtain extension, wound closed • Most common treatment currently • Dermofasciectomy • Similar to fasciectomy but includes removal of affected overlying skin, requires skin graft for closure Treatment Options

16. Recurrence • Pain • Scarring • Injury to vessels, nerves, or tendons • Wound infection • Stiffness • Loss of sensation • Loss of viability • Allergic reaction (enzyme injection) • Tendon rupture (enzyme injection) Risks and Complications of Surgery

17. Hand therapy • Starts within days post-op • Proper splint to protect wound and maintain extension while healing • Increase extension • Maintain flexion/gip • Increase strength • Improve function • Scar management • Improve long-term outcome Post-operative Management

18. Complete extension may not always be possible • Improvement is often partial and temporary • Goal is to regain functional ROM as opposed to full ROM • Repeat procedures are likely less effective with increased risk • 2 in 100 with nodules progress to contracture yearly • Recurrence • Needling – 85% • Enzyme injection – 50-60% (only 5-year follow-up thus far) • Surgery – 20% Outcomes

19. Questions?

20. The End Thank you for your time and enjoy the rest of the conference!