Orthopedics - Oleksa A.P. 2006

Metabolic Bone Diseases
Contractures (contracturae)
Dupuytren's Contracture

Dupuytren's contracture is known in medical literature as palmar aponeurosis, and The Essence of the pathology lies in the scarring of the palmar aponeurosis, leading to flexion contracture of the fingers at the metacarpophalangeal and proximal interphalangeal joints, resulting in impaired hand function.

Although A. Cooper suggested in 1822 that finger contracture was caused by pathological Changes in the palmar aponeurosis, it was G. Dupuytren who, in 1831, detailed the clinical signs and pathomorphological changes of the condition; hence, the disease is named after him.

Dupuytren's contracture occurs more frequently in men over the age of 40.

Unfortunately, the exact Etiology of the condition remains unclear to this day. Several authors believe that the contracture is caused by chronic trauma in athletes or workers of certain professions (such as miners or drillers), which triggers degenerative changes in the palmar aponeurosis followed by scarring. However, because Dupuytren's contracture is frequently bilateral, some orthopedists associate it with pathological changes in the cervical segments of the Spinal Cord in syringomyelia or Spinal osteochondrosis, or with irritation of the sympathetic fibers within the ulnar nerve (Maique R., 1957; Jeiewska E., Kozłowski P., 1960).

Contractures have also been linked to hypothalamic disorders, neuroses, chronic coronary insufficiency, and myocardial infarction (Szymanek D., 1962).

Nevertheless, the primary factor in The Development of Dupuytren's contracture is constitutional and hereditary predisposition, as evidenced by numerous observations of familial inheritance. Contractures associated with diabetes are also likely genetically inherited.

Clinical Features. In most patients, the contracture begins with the appearance of a dense nodule on the palm near the transverse palmar creases opposite the fourth finger. This nodule enlarges very slowly, transforming into a cord that pulls on the overlying Skin. At this stage, hand function remains normal, and the patient experiences no discomfort. This condition may persist for years, but periods of progressive aponeurotic scarring can recur, progressively drawing the skin into a solid dermato-aponeurotic conglomerate. As the scar thickens and contracts, a flexion contracture of the fourth and eventually the fifth finger develops. This contracture gradually worsens as the scar extends to the proximal phalanx, pulling both it and the middle phalanx into flexion (Fig. 105). The flexion can become so pronounced that the tips of the 4th and 5th fingers press against the palm.

Therefore, some specialists distinguish three stages in the development of Dupuytren's contracture:

1) the appearance of a nodule in the palmar aponeurosis;

2) the appearance of a slight flexion contracture of the proximal phalanx that does not impair hand function (inability to fully extend the finger) (Fig. 106);

3) a pronounced flexion contracture of the finger that severely impairs hand function.

As noted earlier, cases of bilateral Dupuytren's contracture do occur; it may develop simultaneously, but more often the Selection/3.html">Stages of development differ between the two hands. The literature describes cases where the pathological process halts at any given stage and ceases to progress.

Similar chronic contractures resembling Dupuytren's disease can also occur on the soles of the feet.

Pathomorphological studies have established that Dupuytren's contracture alters the shape and Structure OF THE palmar aponeurosis, transforming it into a dense, nodular scar that draws in the skin and tendon sheaths, while the tendons within the sheaths remain free and mobile. However, prolonged and severe flexion contractures eventually lead to secondary changes in both the tendons and the joint capsules of the Phalanges.

Histological examination of the aponeurosis reveals its transformation into dense Fibrous Connective Tissue of a tendinous type, accompanied by the proliferation of characteristic Cells. Histochemical analysis of these proliferative areas demonstrates an accumulation of mucopolysaccharides, indicating metabolic disturbances within the mucopolysaccharide complexes of the connective tissue.

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Fig. 105. Grade I Dupuytren's contracture.

Fig. 106. Mild Dupuytren's flexion contracture of the 4th and 5th fingers of the left hand.

Treatment. Conservative management of Dupuytren's contracture—including massage, ultrasound, local corticosteroid injections, ronidase, lidase (6–7 IU per injection, 20 injections per course), and hyaluronidase—fails to yield satisfactory results. Forced extension of the finger during the Cytology/cytology/16.html">Early stages of contracture typically exacerbates the condition. Some temporary improvement may be observed following paraffin-ozokerite Applications and thermal therapy during the initial stage of aponeurotic scarring.

The most radical and effective treatment is surgery—the excision of the pathologically altered Tissues. The Procedure should be performed during the Second Stage of aponeurotic scarring, before coarse scar conglomerates develop, as these are technically difficult to remove in advanced stages. Late interventions typically result in skin and tendon sheath defects, and volar capsulotomy is sometimes required to straighten the finger. The later the surgery is performed, the poorer the postoperative functional outcomes, regardless of the subsequent use of lidase and physical therapy.

Prior to surgery, The Scope of the procedure must be determined, as both partial excision of the palmar aponeurosis (removing the pathologically altered tissue within healthy margins) and extensive excision are practiced.

Subcutaneous fasciotomy is no longer employed due to its lack of efficacy.

Skin incisions are of critical importance and must be planned individually, taking into account the Anatomical Features of the palm, scar changes, and the degree of contracture. The incision should not cross the palmar-digital crease; therefore, separate incisions are used on the palm and the affected fingers. Z-plasty skin incisions improve access to the palmar aponeurosis, prevent complications, and facilitate wound closure (Fig. 107).

The operation is performed under general anesthesia using a forearm tourniquet. Following the skin incision, the flap edges are very carefully dissected directly off the aponeurosis to avoid perforation at sites of dense adhesion. The pathologically altered aponeurosis is excised within healthy tissue margins after first dividing its longitudinal and transverse fibers, followed by the vertical ones. Following such an intervention In the second stage of the process, the finger can be straightened effortlessly; therefore, the operation is concluded by draining and suturing the wound. The hand is immobilized in a plaster splint with the finger slightly flexed to prevent skin tension on the palm. Once the wound has healed, mobilization exercises and physical therapy are initiated.

Significant difficulties arise during surgery for severe (stage III) Dupuytren's contracture. The cicatricially degenerated slips of the aponeurosis, which are the main cause of the flexion contracture, attach to the sides of the phalanges near the digital Vessels and nerves. Therefore, surgery must be performed with extreme caution to avoid injuring them (Fig. 108).

We witnessed a case of finger amputation resulting from necrosis following such a procedure. If a digital vessel or nerve is damaged, its integrity must be restored immediately, either by the surgeon or by calling in a microsurgery specialist.

Sometimes a skin defect occurs during the operation, making it impossible to close the wound edges. In such cases, the wound should be covered with a skin graft (perforated, if necessary). It is preferable to choose a donor site where Hair does not grow. We once had to recommend a repeat skin autograft because the patient was cosmetically dissatisfied with the hair growing on his palm.

Fig. 107. Subcutaneous dissection of the palmar aponeurosis.

Fig. 108. Stages of subcutaneous aponeurosis excision from the contracted finger area following a zig-zag skin incision (Strieland J.W., 1993).

Cases of marginal skin necrosis may occur due to ischemia during undermining or from excessive suture tension. Once necrosis is clearly demarcated, necrectomy is performed with primary autodermoplasty or delayed closure on a granulating wound. To prevent necrosis, the Blood supply to the Skin must be preserved, and the finger should be immobilized postoperatively for 5–7 days in a slightly flexed position.

Gradual full extension of the finger is achieved after the wound heals. Patients undergo physical therapy while simultaneously performing active and passive finger exercises.

Among the complications of such operations, suppuration of subcutaneous postoperative hematomas should also be noted. Blood accumulation occurs when closed postoperative wounds are not drained for 24–48 hours. Signs of potential suppuration include Swelling and local or systemic hyperthermia. If probing between sutures reveals even a drop of pus upon separating the wound edges, sutures must be removed over a sufficient length, and the wound managed According to the principles of purulent surgery. Some complications worsen the functional outcomes of surgery and may even lead to contracture recurrence.

Today, the "open palm" technique, proposed by McCash in 1964, is considered the most rational approach. It is performed for all grades of finger flexion contracture accompanied by hand deformity and impaired finger function. Contraindications for surgery may include mental status disorders in elderly patients, vasotrophic disorders in the hand, and exacerbations of somatic diseases.

The essence of the procedure involves making 3–4 physiologically grounded transverse skin incisions along the palmar creases (Fig. 109), subtotally excising the pathologically altered palmar aponeurosis, straightening the fingers, and allowing the wounds to heal by secondary intention (without suture placement).

Surgical technique. The first transverse incision is made parallel to the proximal palmar crease. The skin and subcutaneous tissue are sharply dissected and undermined from the palmar aponeurosis in both proximal and distal directions. A slightly curved grooved probe or curved clamp is inserted beneath the cords of the scarred aponeurosis, and the proximal portion of the aponeurosis is transected and excised over it. If Carpal tunnel syndrome is diagnosed, the flexor retinaculum is divided by one-third from the palmar side. Next, the distal portion of the aponeurosis is excised by cutting its vertical bands.

The second skin incision is made along the distal palmar crease. This is the longest incision, as it must provide adequate access to the aponeurosis at the Base of the affected fingers. The palmar aponeurosis is excised in a similar manner.

Fig. 109. "Open palm" technique for Dupuytren's contracture: 1 - transverse skin incisions on the palm and fingers after excision of the pathologically altered aponeurosis, 2 - secondary healing of the wounds, 3 - appearance after wound healing.

The third incision is made along the palmar-digital crease, and the remaining aponeurotic cords are removed through the created channel. If the digital component of the contracture predominates, an additional incision must be made in the region of the proximal interphalangeal joint to excise the slips of the aponeurotic cords. The contracted fingers are straightened carefully to avoid causing paresis. After finger extension, the wound edges part, especially in the area of the distal palmar crease. Aseptic dressings moistened with a 1:5000 furacilin solution or furacilin with glycerin are applied to these wounds. The hand is immobilized with a dorsal plaster splint with the fingers in an extended position.

Wound dressings are changed daily; during dressing changes, the patient must actively flex and extend the fingers several times and make a fist. In the postoperative period, the patient is prescribed Antibiotics, local hypothermia, vasodilators, and antispasmodic agents, followed by physical therapy. It should be noted that the "open palm" procedure has proven itself in clinical practice, does not require skin defect closure with autografts during surgery, and results in linear scarring when postoperative patient management and compliance are properly maintained.

A drawback of this operation is slow wound healing (up to 1.5–2 months). However, the long-term cosmetic and functional outcomes of the "open palm" procedure for Dupuytren's contractures have proven to be superior, with complications and recurrences being virtually nonexistent.