Contracture is a restriction of mobility in a joint that occurs due to changes in the articular surfaces or soft tissues functionally associated with the joint.
There are flexion contractures, extension contractures, abductor contractures, adductor contractures and others.
Joint contractures can be congenital or acquired in origin.
Congenital joint contractures are based on underdevelopment of the muscles and joints themselves (torticollis, arthrogryposis, clubfoot).
Acquired joint contractures can be:
- neurogenic - as a result of disease or injury to the nervous system
- post-traumatic - as a result of intra-articular or periarticular injuries, injuries or burns of soft tissues with subsequent development of scars
General information. What is Dupuytren's contracture?
Dupuytren's contracture (ICD-10 code - M72.0) is a rather serious age-related disease, the cause of which is cicatricial degeneration of the tissue structure of the palmar aponeurosis, which leads to limitation, and sometimes to complete cessation of the flexion function of the fingers (one or more) of the hand .
According to Wikipedia, this painful condition got its name in honor of the outstanding French physician and scientist Guillaume Dupuytren, who in the 19th century managed to study this pathology and even develop the first methods of treating it. In modern medicine, Dupuytren's contracture is often referred to as palmar fibromatosis .
Photo, what is Dupuytren's contracture
This disease does not pose a threat to the patient’s life, but is considered one of the primary causes of a person’s loss of ability to work. If this pathology is recognized in the early stages, its further development can be prevented to some extent with the help of conservative therapy, and in case of late diagnosis, it will most likely be necessary to resort to surgical intervention.
Clinical picture
Typically, Dupuytren's contracture does not appear immediately; it can develop over years. Although in some cases this may take several months or even weeks. The disease mainly affects men of European descent. It begins with the skin on the palm becoming thicker, causing folds and dimples to form on it. As the disease progresses, tufts of fibrous tissue form in the palm area, which can spread distally towards the fingers. This thickening and shortening leads to flexion deformity of the fingers. Most often, Dupuytren's contracture affects both hands, and it is more pronounced on one of them.
Pathogenesis
According to worldwide medical statistics, palmar fibromatosis affects approximately 3% of the population of our entire planet. In the vast majority of cases, it affects mature men aged 40 to 60 years. In women, Dupuytren's contracture is found only in 4-8% of cases.
Stages of development of Dupuytren's contracture
Depending on how severe the contracture of the fingers is in the patient, there are 4 stages of development of this disease.
Stage one
In the area of one of the palmar tendons (most often under the ring finger), a subcutaneous seal appears in the form of a small nodule. This neoplasm does not cause any pain and does not interfere with any manipulation performed by the hand. All fingers at this stage retain their usual mobility. Often, a working person mistakes such a nodule for a callus .
Stage two
The disease progresses through the transformation of the subcutaneous node into a scar cord with its transition to the proximal digital phalanx. Also in the area where such a cord appears, changes in the skin are observed, expressed by their hardening and redness. There is a violation of the mobility of the damaged finger, which is in a bent position at approximately an angle of 30° relative to the palm and cannot be fully extended. There is most often no pain.
Stage three
The fibrous band extends over the entire surface of the finger and can extend up to its distal phalanx. The skin along the scar becomes wrinkled and folded. The affected finger is in a position of approximately 90° relative to the palm, with a sharp limitation of its functionality and contracture of the hand as a whole. In most cases, the pain syndrome does not manifest itself or is mild, but any manipulation of the hand is extremely difficult. ankylosis (fusion of joint surfaces) is already possible
Stage four
Pathological cords affect several fingers or even the entire palm. Often they grow together into a common large scar. The first affected finger is in a completely flexed position without any possibility of extension, and the rest of the hand is severely deformed. Subluxations and dislocations of the interphalangeal joints may occur, in which the patient will feel constant aching pain. The performance of the hand in this period is virtually zero.
Outcome assessment
Since flexion contracture of the fingers is one of the main disorders in Dupuytren's disease, range of motion should be measured at the metacarpophalangeal joints, proximal interphalangeal joints, and distal interphalangeal joints. It is necessary to measure active and passive flexion and extension. The data obtained will serve as the initial value. These measurements should be taken throughout the treatment process as they can also be used to determine the severity of contractures.
It is also important to assess the patient's hand function. To do this, you can use tests and questionnaires, such as DASH, or its shorter version, The Quick Dash. The DASH questionnaire is a 30-question questionnaire. It focuses on assessing function and symptoms in patients who have upper limb problems. Another hand and arm assessment tool is the Short Form-36. This is a 36-question questionnaire that is more general in nature and is used when working with various diseases. It can be useful in determining the patient's overall health and well-being.
Causes
Despite the fact that such a disease as Dupuytren's contracture has been described for quite a long time, and methods of combating it with the development of medicine are constantly reaching a new, more effective level, it has not yet been possible to establish the specific cause of this pathology. In the process of studying this disease, a hereditary risk factor for its formation was clearly proven, since a gene was isolated that is present only in the genome of people with a family history of palmar fibromatosis. However, not all carriers of this gene show signs of the disease; many of them never face this problem until the end of their lives.
Apparently, contracture of the hand develops only in people predisposed to it when the hand is exposed to a combination of risk factors for its occurrence, which include:
- bad habits ( smoking , alcoholism , etc.);
- injuries in the hand area (including minor multiple and/or single serious injury);
- professional activity (working conditions associated with constant and heavy load on the hand);
- age-related changes in the structure of hand tissues;
- gender (males suffer from palmar fibromatosis much more often);
- concomitant systemic pathologies ( diabetes mellitus , liver disease , epilepsy , etc.).
According to many orthopedic doctors, when the above factors influence the carrier of the gene responsible for the formation of Dupuytren's contracture, pathological processes are activated in the area of the palmar aponeurosis, resulting in degeneration of tendon tissue, and consequently to the emergence and further progression of palmar fibromatosis.
Diagnosis of joint contracture
Symptoms and course of joint contracture depend on:
- causes of contracture
- localization of the affected joint
- patient's age
In chronic pathological processes, contractures develop slowly, and in acute inflammatory processes in joints, muscles and other tissues - quickly. The more severe the pathological process, the more pronounced the contracture.
Contracture is especially pronounced in diseases and injuries of the joints, often accompanied in these cases by atrophy of the soft tissues above and below the contracture. If contracture develops in childhood, the limb is stunted.
To clarify the nature of changes in the affected joint, the following is required:
- consultation with a doctor is the first step to determine the functionality of the joint
- CT (computed tomography) of the joint
- MRI (magnetic resonance imaging) of the joint
- radiography of the joint
Symptoms
As is the case with the stages of development of Dupuytren’s contracture, doctors identify 4 conventional stages of progression of this pathology, each of which corresponds to certain negative symptoms.
Preclinical stage
During this period, symptoms typical for palmar fibromatosis do not yet appear, but the patient may already feel heaviness and fatigue in the problem hand, numbness in the fingers, morning stiffness, and aching pain in the hand. In some cases, dry skin of the palm is observed, its slight thickening and smoothing of skin folds on it. As a rule, the first cycle is quite long and can last up to 8 years.
Stage of initial manifestations
At this stage, the patient already notices the first, most often visual, symptoms of the disease, which is manifested by initial atrophic changes occurring in the subcutaneous fatty tissue of the palm. At this time, for the most part, a subcutaneous node (sometimes several) appears under one of the fingers (ring or middle), and the finger itself “pulls” a little towards the palm. There may also be small indentations in the skin around the nodes. This stage proceeds much faster and takes an average of 2 years.
Intensive Progression Stage
The affected area of the palm at this stage gradually increases and expands. Under the skin, not only tubercles and nodules are visible, but also hard cords formed from connective tissue. Such cords can run along one (in most cases) or several fingers and are especially noticeable when the patient tries to straighten them. In this case, there is a clear flexion contracture, in other words, the inability to fully straighten the fingers.
All this happens due to the degeneration of tendon tissue into scar tissue, which causes it to lose elasticity and shorten. At the same time, areas of inflammation and peeling appear on the skin of the palm, as well as clearly visible depressions in the area of its folds and funnel-shaped “retractions”. The skin itself becomes dense and rough, and in some cases bedsores .
Late stage
The borderline stage of palmar fibromatosis is characterized by the spread of the pathological process to virtually the entire area of the palm. Flexion contractures are observed in several or even all fingers. Fibrous ankylosis is clearly defined and is often accompanied by subluxations and dislocations of the finger joints. The skin is dense, dry and has a rough structure. Subcutaneous fat is most often already atrophied. There is simply no room for the disease to progress further, since at this stage the functionality of the hand is maximally impaired and even to partially restore it, more than one operation will be required.
It should be remembered that pain may practically not appear in the first stages of Dupuytren's contracture, and in its later stages it is observed only in 10% of patients. All the main symptoms of this disease are mainly visual. For this reason, early diagnosis of this pathology is difficult and largely depends on the attentive attitude of each individual person to their health.
Tests and diagnostics
Diagnosis of palmar fibromatosis, as a rule, does not require the appointment of any instrumental or laboratory tests or analyses. Such a diagnosis is made by an orthopedic doctor based on the visible picture of the condition of the hand and the patient’s specific complaints. radiography is used for differential diagnosis .
In order to independently detect Dupuytren's contracture, you can perform a small test at home to detect or exclude signs of the formation of this disease. The test for the presence of palmar fibromatosis consists of the following steps:
- Press your hand palm down onto a flat horizontal surface and check for a gap between the surface you are using and your palm.
- In the absence of this, Dupuytren's contracture is unlikely.
- If a small arcuate gap is detected, the second stage of the disease can be suspected.
- A significant similar gap in the form of a kind of “hut” may indicate the third stage of palmar fibromatosis.
Treatment with folk remedies
Along with drug therapy, treatment of Dupuytren's contracture at home using traditional methods is not able to completely relieve the patient of all manifestations of the disease, but can to some extent alleviate his painful condition. In this case, the most suitable means of traditional medicine are considered to be warm compresses, baths and gymnastic exercises.
- For example, a bath based on pine needles, which is prepared by boiling 500 grams of fresh pine needles (spruce, pine) in 1 liter of water for half an hour, will help reduce pain in the area of existing contracture. After this procedure, the resulting decoction is infused for 24 hours, mixed with sea salt (1/6 of a glass) and used for its intended purpose. Before using the bath, it is recommended to warm the pine decoction to a temperature slightly above body temperature.
- Also, the method of Kalmyk folk therapy, which involves the use of fresh sawdust, clay and horse manure in the form of applications, mixed in equal proportions, has received good reviews in reducing the symptoms of palmar fibromatosis. A similar composition should be applied warm to the affected hand twice a day. The specificity of one of the ingredients of such a remedy naturally repels some patients from its use, although people who have tried this method on themselves note its considerable effectiveness.
- A herbal bath prepared by boiling equal parts (1 tablespoon each) of eucalyptus, calendula and chamomile in 1 liter of water has also proven itself well in this regard. After boiling this mixture of herbs for 10 minutes, it must be infused for 2-3 hours, then strained and added with 1 tbsp. l. sea salt. Before the procedure, the broth is heated to a temperature of approximately 50°C and the problematic brush is steamed in it for 20-30 minutes.
- In turn, chestnut infusion will help cope with the negative symptoms of the disease. To prepare it, you need to chop fresh chestnuts and fill a 0.5 liter jar with this pulp, leaving 2-3 centimeters of free space on top. After this, you should fill the jar to the top with ammonia and put it in a dark place for 9 days. After this time, you should use the resulting mixture as a rub, which can be used 2-3 times a day for 2 months.
All these and other similar methods of traditional medicine are best combined with gymnastic exercises aimed at improving the motor activity of the damaged hand. In this aspect, you can select any training for your fingers, during which their motor skills will be involved. Among other things, knitting, modeling, typing, playing keyboard instruments, etc. have a positive effect on the palmar aponeurosis.
Despite the abundance of thermal methods of influencing the affected tissues and a huge number of various exercises that help restore the motor function of the fingers, reviews of the treatment of Dupuytren's contracture with folk remedies note their rather weak effectiveness. Therapy for such a serious pathology must be carried out by a specialist, but even in this case there is no one hundred percent guarantee of its cure.
Operation
The fibrous cord can not only be cut under the skin, but also completely removed. The main advantage of open surgery is the most complete and long-lasting effect compared to closed methods.
The main disadvantage of a full-fledged operation is the longer recovery. The sutures are removed after 2 weeks and the same or even more may be needed to restore function.
In any case, no matter what treatment method we choose, I have no reason to admit the patient to the hospital. Any treatment for Dupuytren's contracture can be performed on an outpatient basis using local anesthesia (unless, of course, you are allergic to local anesthetics).
Prevention
Until today, doctors have not been able to accurately determine the true causes of Dupuytren's contracture, as a result of which specific preventive measures for this disease are not provided. In order to reduce the risk of developing this pathology, orthopedists recommend that everyone (especially men) with a family history of palmar fibromatosis stop smoking and drinking alcohol in large quantities. Such people should choose professions that do not involve heavy manual work, and also try to eat a balanced diet.
Treatment after surgery
Immediately after suturing the skin, a large sterile bandage is applied, and the hand is placed on a scarf. During the first day, a lot of blood is usually released, so I always wrap a thick “mitten” around my hand. For the first 2-3 days, the hand should be held higher, trying not to lower it below the level of the heart. As soon as the anesthesia wears off (which is 3-4 hours after surgery), you should take painkillers.
Before the stitches are removed, we will meet several times, gradually your “mitten” will become thinner, and your arm will hurt less and less. After 2 weeks, the stitches are removed. It does not hurt! Sometimes it happens that the bandage remains on the arm even after the stitches are removed. With severe contracture, marginal necrosis of the flaps and longer healing of the transverse approach are possible.
After the wound has healed, you can wash your hand and start using it. Under the scars, the skin is initially hard and inactive. It needs to be softened with massage, hand cream, movements and physiotherapeutic procedures.
NB! Classes with a hand therapist improve the results of treatment of Dupuytren's contracture.
Plaster and other means of immobilization are used very rarely, only in special cases.
Full restoration of hand mobility after open aponeurotomy should be expected no earlier than 2 months.
Consequences and complications
Do not forget that palmar fibromatosis is a rather serious disease, which, if diagnosed by a doctor untimely or the patient is unwilling to undergo treatment, will most likely lead to the complete loss of the hand’s functionality, and possibly to amputation of the fingers. In order to avoid such extremely negative consequences, any person who suspects the development of this pathology should immediately seek medical help and subsequently follow all the recommendations of the orthopedist, including regarding surgical intervention.
Forecast
Predicting the course of Dupuytren's contracture is quite difficult, since the development of this disease in individual patients can occur in completely different ways. In some cases, a slight limitation in the motor activity of the hand can accompany the patient for many years, while in others the disease simply progresses rapidly.
Be that as it may, palmar fibromatosis will sooner or later reach its borderline stage and then the only way out of the situation will be surgery.
List of sources
- Treatment of patients with Dupuytren's contracture (clinical recommendations) - “Nizhny Novgorod Research Institute of Traumatology and Orthopedics”, A.V. Novikov, S.V. Petrov. Nizhny Novgorod, 2013
- Asfura I.I. Complex treatment of Dupuytren's disease. Author's abstract. Ph.D. Minsk. 1986. - 16 p.
- Volkova A.M., Kuznetsova H.JI. Dupuytren's contracture (classification, clinic, diagnosis, treatment, clinical examination). Methodological recommendations for practicing doctors. Sverdlovsk 1986. - 16 p.
- Gerasimenko S.I. Dupuytren's disease and its complex treatment. Author's abstract. dis. Ph.D. Kyiv. 1982. - 20 p.
- Mikusev I.E. Dupuytren's contracture (issues of etiology, pathogenesis and surgical treatment). Kazan. 2001. - 175 p.
Medication injections
Injecting drugs directly into fibrous tissue can soften or destroy it.
At the time of writing (May 2021), the situation in Russia is as follows:
Pfizer's drug Xiapex is not registered. It is the only collagenase in the world certified for the treatment of Dupuytren's contracture.
Collalysine is not certified for the treatment of Dupuytren's contracture, and I have never learned how to achieve the right concentration.
Fermenkol is at the stage of certification of the injection form.
Kenalog (not an enzyme, but a glucocorticoid) is certified for local injection and is an excellent softener for fibromatous nodes.