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Cascade Orthopaedics Practice Newsletter
December 2013
Thanks for being a patient of Cascade Orthopaedics! While many patients visit us for a specific problem, they or their loved ones often have other unrelated orthopaedic concerns. We are producing a monthly newsletter with the intent to provide a source of information and to serve as an educational resource for our patients on some common problems, and give advice on maintaining musculoskeletal health. Our goal is to help you prevent problems, and recognize what conditions might be causing pain and disability. We may also suggest resources that might be available to help you prevent or manage problems.  Cascade's Website
 

DUPUYTREN'S CONTRACTURE  

 

"My fingers are drawing down into my hand!"

 

"What are these lumps and cords in my palm and fingers?"

 

Many people come into the clinic each week with a interesting problem where they develop, for no apparent reason, lumpy cords in their palm that seem to be pulling their fingers down.  This is called Dupuytren's contracture.

 

OVERVIEW    

 

Dupuytren's contracture is a problem that typically presents at age 50 or older.  It commonly affects the ring and small finger, and can often develop in both hands, but not necessarily evenly.  It is much more common in men than women, and is most often seen in white people.  It has a strong genetic predisposition, so we often see it passed down from parent to child.

 

 

People often suspect that Dupuytren's contracture is do to some type of injury or overuse, but that is rarely the case. It can be associated with certain medical conditions.

Initially, the changes in the hand are barely noticeable, but as time passes, the disease almost invariably progresses. The fingers slowly pull down farther into the palm, lumps can form and grow along the cords, and the skin may pit or pucker. Fortunately, the condition is usually not painful. People who develop the problem complain mostly that their hand is awkward, and will not open to put in the pocket or into a glove, and their bent finger gets in the way. Given time it can progress quite significantly, and multiple fingers can become affected.

Unfortunately, there is no known effective prevention for the disease, and their is no proven way to keep the contractures from progressing. Every patient seems to have a different course of the disease, as some progress slowly, some quickly. Some patients have multiple affected areas, others few.

As a rule, the younger one is when the process begins, the more of a problem it typically will develop into in time.

 

Treatment

 

Treatment is not recommended early on, when the contractures are mild. Treatments are targeted in releasing or removing the offending cords. It is important to realize that the cords are not tight tendons; they are abnormal fibrous "scar" type tissue composed of dense, strong bands of collagen fibers. The goal of treatment is thus to remove or break up those offending bands.

 

As the disease was described in the 1800's, it has a long history of treatment. Over the decades, the most reliable gold standard for treatment was hand surgery. In this process, large incisions are made where the abnormal tissue is identified and removed surgically, thus, un-tethering the finger(s) and removing the knots of fibrous tissue. While this treatment is largely very helpful, it is a significant operation that offers a relatively slow healing process typically over several months.

  

Fortunately, in recent years, two newer, less invasive methods of treatment have become available and more widely used in the United States.

The first is called Needle Aponeurotomy. In this procedure, a small typical hypodermic needle is inserted along the cord, under a local anesthetic, and used as a tiny knife to cut the fibers of the cord, thus releasing the contracture. 

 

 

The procedure is minimally invasive, and recovery is typically a matter of days until resumption of nearly normal activity.  

  

 

 

The third way doctors have been treating Dupuytren's contracture of late is by use of the drug Xiaflex or collagenase.  This is an enzyme secreted by a dangerous bacteria that can be harvested and used as a tool.  The enzyme acts to break up collagen fibers.  A tiny amount of it is injected into the offending cord, and acts in eating away at the collagen fibers.  During a subsequent procedure a day or two later, the cord is stretched and often tears, releasing the finger to be straighter.

 

 

 

Xiaflex has been on the market for just under 3 years and results are encouraging. The downside is that it may require multiple injections for maximum effect, and the medication itself is quite expensive.

No matter how Dupuytren's contracture is treated, one can never really "cure" the disease. It is always possible for it to recur in new or previously treated areas. Our goal, then, is to attempt to control the process as effectively as possible.

Every patient's Dupuytren's disease presents differently, so it is important to get the opinion of an experienced hand surgeon for the best treatment ideas. Drs. Blauvelt and Smith at Cascade Orthopaedics are both fellowship trained hand specialists with extensive experience in treating patients with Dupuytren's disease using the latest of techniques and tools. If you have questions or wish to schedule an evaluation, please call us at (253)833-7750, and ask to be scheduled with one of our hand specialists.

You can also check out the website DupuytrensinSeattle.com for a more detailed discussion and link to further resources on the subject.
 



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