Dupuytren’s contracture - possibilities of the therapy, shock wave application

This illness of the hand was first described in 1831 by baron Guillaume Dupuytren. The base of the Dupuytren’s contracture is formation of nodules and thickening of palmar aponeurosis (thin ligamentous membrane, which is spreaded tendon). Anatomically it is an attachment m. palmaris longus. Continuation of this process leads to flexive shortening (bending) of the finger, which can be hardly corrected. Among average people there is an incorrect belief, that is „shortening of the tendons”, however tendons of the finger flexors are in order. The illness is usually by men above 50 years of age. The cause is till this day partly unclear. The reason can be immunologic disorder, mechanical, thermal or chemical damage of the soft tissues in the palm, inflammation , heavy physical work, injury of the hand…

SYMPTOMS

First symptoms are manifested on the pinky side from the fourth and fifth finger. The skin of the palm is as if sticking to the lower layers of the soft tissues. This adhesion restricts the mobility of the finger in a direction to extension. That is transferred in matter of weeks or even months to other fingers. The tension of the palmar aponeurosis causes the flexing of the fingers towards the palm. In serious cases the fingers are bent nearly in a fist without the option of extending them. Similar symptom is also by Ledderhose’s disease.

TEST

The hand test - client is not able to place the hand on the table or place hands against each other (such as during praying).

EVALUATION THE PROGRESS

  • 1st degree - formation of nodules in the hand 
  • 2nd degree - starting contractures of the metacarpophalangeal joints (flexing in the primary joints)
  • 3rd degree - contracture of the fingers in the proximal interphalangeal joints (flexing in the joints on the ends of the fingers)
  • 4th degree - compensating hyperextension of the distal joint (bending the fingers in the basic joint in the back)

CLdupuytrenovakontraktura

SURGICAL OPTIONS OF THE TREATMENT

Because the cause is not entirely known, it is not possible to cure the cause. Nowadays the most common type of surgery is excision (stretching) aponeurosis (thin ligamentous membrane, which is a spreaded tendon in the hand). The doctors recommend surgery already by a positive hand test.

  • Closed aponeurotomy - severing the contracting line of aponeurosis by tenotomy from a minimal incision, there is no need for recovery
  • Limited aponeurotomy - removed part of the aponeurosis, which causes problems
  • Partial aponeurotomy - removed surrounding fasciitis (sheath of the muscles)
  • Radical (total) aponeurotomy - removed whole aponeurosis

PHYSIOTHERAPY

Physiotherapist can help with gradual worsening function of bending the fingers thanks to positioning or placing the hand in orthosis. Relaxation of aponeurosis, may be subjective, can be achieved by paraffin wax and warmth from the hot rolls according to Dr. Brügger

Hot towel roll

Stretching the tendons and muscles of the flexor group of the fingers and wrist causes more traction or slow down of gradual degeneration of the hand.

From available physical therapy, the most common one is ultrasound and magnetotherapy. From a practical point of view they don’t have any significant meaning. Unfortunately the laser or biolamp doesn’t have a big effect.

SHOCK WAVE

Unlike the mentioned non-invasive (unburdened) methods, in FYZIOklinika in Prague we have during application of the radial shock wave very good results. We observe after several applications, reduction in size of the nodules, relieved tension of the adhesion and increased mobility of the fingers. Clients rate the therapy subjectively , they feel a positive change and relief from the tension.

A rule applied here that the earlier you start with the shock wave treatment, the better results you can expect from the treatment of the problem.



Author:
Mgr. Iva Bílková, FYZIOklinika fyzioterapie Ltd, Prague. Czech Republic

Source: Clinical experience from a private practice in a physiotherapeutic field, FYZIOklinika, study materials for medics, informations gained during study on university

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