The Search for Successful Conservative Care for Dupuytren's DiseaseNonoperative treatment of Dupuytren's disease just isn't a reliable way to treat Dupuytren's disease. Dr. G. M. Rayan from the INTEGRIS Baptist Medical Center in Oklahoma City, Oklahoma reviews the main options available in conservative care for this problem. Best available evidence was used to show that surgery is still the most effective way to treat Dupuytren's.
Dupuytren's contracture is a fairly common disorder of the fingers. The palmar fascia (connective tissue of the palm) contracts, or tightens. This contracture is like extra scar tissue just under the skin. Without treatment, the contracture can become so severe the finger no longer straightens. It most often affects the ring or little finger, sometimes both, and often in both hands.
At first, when this condition is mild, careful observation is advised. If the contracture stays the same and doesn't get worse, it may be referred to as nonDupuytren disease. If hand function is not impaired, there may be no reason to treat the problem aggressively.
Other nonoperative treatment options include physical therapy, radiation therapy, vitamin E, and injection therapy. Each of these modalities is discussed briefly in this article.
Stretching with the application of ultrasound may be helpful in the early stages of Dupuytren contracture. Ultrasound can break the disulfide bonds that hold collagen tissue together. Stretching the tissue during the heat treatment is needed to lengthen and realign the structure.
Range-of-motion exercises should be done several times a day to maintain this new tissue placement. The physical therapist may also recommend that the patient wear a custom splint or brace at night. This will keep the fingers straight and stretch them. All of these physical therapy techniques are designed to slow the progression of the contracture. Studies to prove the effectiveness of this approach have not been done yet.
Radiation therapy and vitamin E treatment were tried and abandoned in the 1950s. There was no evidence to support their continued use. Cortisone injected into the painful nodules can ease pain and inflammation. But this is only a temporary solution. And it can lead to skin color changes and tendon rupture.
Other chemicals can be injected into the lesion as well. Scientists have studied the effects of pharmaceutical agents used this way in both early- and advanced-stage disease. The hope is to find a way to stop the collagen from overproducing. Suppressing the disease without adding extra complications may be possible in the future.
Enzymes have also been used in an attempt to dissolve the collagen. Then forcible stretching of the affected finger is used to manually rupture the diseased cord thereby releasing the contracture. This type of enzyme treatment is still considered investigational by the FDA.
With any kind of injection therapy, there are possible complications. There can be local pain and swelling or the formation of a hematoma (pocket of pooled blood). Damage to the nearby nerves can cause numbness and possible motor involvement with additional weakness of the tendons and muscles of the hand.
All nonoperative treatments of this condition have a high rate of recurrence. In rare cases, a surgeon may inject the area with a numbing agent and use a surgical blade to cut the cord in half. This procedure is called a percutaneous and needle fasciotomy. Percutaneous refers to making a small incision and passing the blade under the skin.
Recurrence of the contracture is common after fasciotomy. It is a technique used most often with older patients, people in poor health, or as a first step to fasciectomy (removal of the tissue).
Studies so far indicate the best success when using fasciectomy. Surgery doesn't cure the problem, but it can control it. Reducing the contracture's pull on the joints may also help prevent damage to the articular cartilage but this hasn't been proven yet either.
Ghazi M. Rayan, MD. Nonoperative Treatment of Dupuytren's Disease. In The Journal of Hand Surgery. September 2008. Vol. 33A. No. 7. Pp. 1208-1210.
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