Disclaimer This movie is an educational resource only and should not be used to manage Orthopaedic Health. All decisions about must be made in conjunction with your Physician or a licensed healthcare provider.
MULTIMEDIA HEALTH EDUCATION MANUAL TABLE OF CONTENTS SECTION CONTENT 1. Normal Hand Anatomy a. Introduction b. Normal Hand Anatomy 2. a. What is Dupuytren's Contracture? b. Signs and Symptoms c. Causes and Risk Factors d. Diagnosis e. Conservative Treatment Options 3. Surgical Procedure a. Introduction b. Surgical Treatment c. Post Operative Care d. Risks and Complications
INTRODUCTION Dupuytrens Contracture is a hand condition where thickening of the underlying tissues of the palm causes the fingers to bend inward towards the palm. Patients with this conditions are unable to fully straight the affected fingers.
Unit 1: Normal Hand Anatomy Introduction To learn more about Duputytren's Contracture, it is important to understand the normal anatomy of the hand. (Refer fig. 1) (Fig. 1) Normal Hand Anatomy The hand in the human body is made up of the wrist, palm, and fingers. The most flexible part of the human skeleton, the hand enables us to perform many of our daily activities. When our hand and wrist are not functioning properly, daily activities such as driving a car, bathing, and cooking can become impossible. (Refer fig. 2) The hand in the human body consists of: 27 Bones 27 Joints 34 Muscles Over 100 ligaments and tendons (Fig. 2) Numerous Blood vessels, verves, and soft tissue. 27 Bones (Refer fig. 3) (Fig. 3)
27 Joints (Refer fig. 4) Unit 1: Normal Hand Anatomy (Fig. 4) 34 Muscles (Refer fig. 5) (Fig. 5) Over 100 ligaments and tendons (Refer fig. 6) (Fig. 6) Numerous Blood vessels, nerves, and soft tissue. (Refer fig. 7) (Fig. 7)
Unit 1: Normal Hand Anatomy The wrist is comprised of 8 bones called carpal bones. These wrist bones connect to 5 metacarpal bones that form the palm of the hand. Each metacarpal bone connects to one finger or a thumb at a joint called the metacarpophalangeal joint, or MCP joint. This joint is commonly referred to as the knuckle joint. (Fig. 8) (Refer fig. 8) The bones in our fingers and thumb are called phalanges. Each finger has 3 phalanges separated by two joints. The first joint, closest to the knuckle joint, is the proximal interphalangeal joint or PIP joint. The second joint nearer the end of the finger is called the distal interphalangeal joint, or DIP joint. The thumb in the human body only has 2 phalanges and one interphalangeal joint. (Refer fig. 9) (Fig. 9) Our hand and wrist bones are held in place and supported by various soft tissues. These include: Cartilage Shiny and smooth, cartilage allows smooth movement where two bones come in contact with each other. (Refer fig. 10) (Fig. 10)
Unit 1: Normal Hand Anatomy Tendons Tendons are soft tissue that connects muscles to bones to provide support. Extensor tendons enable each finger to straighten. (Refer fig. 11) (Fig. 11) Ligaments Ligaments are strong rope like tissue that connects bones to other bones and help hold tendons in place providing stability to the joints. The volar plate is the strongest ligament in the hand and prevents hyperextension of the PIP joint. (Refer fig. 12) (Fig. 12) Muscles Muscles are fibrous tissue capable of contracting to cause body movement. Interestingly, the fingers contain no muscles. Small muscles originating from the carpal bones of the wrist are connected to the finger bones with Tendons. These muscles are responsible for movement of the thumb and little finger enabling the hand to hold and grip items by allowing the thumb to move across the palm, a movement referred to as Thumb Opposition. The smallest muscles of the wrist and hand are responsible for fine motor movement of the fingers. (Refer fig. 13) (Fig. 13) Nerves Nerves are responsible for carrying signals back and forth from the brain to muscles in our body, enabling movement and sensation such as touch, pain, and hot or cold. The three main nerves responsible for hand and wrist movement all originate at the shoulder area and include the following: (Refer fig. 14)
Unit 1: Normal Hand Anatomy (Refer fig. 14) (Fig. 14) Radial The radial nerve runs down the thumb side of the forearm and provides sensation to the back of the hand from the thumb to the third finger. (Refer fig. 15) (Fig. 15) Median The median nerve travels through the wrist tunnel, also called carpal tunnel, providing sensation to the thumb, index finger, long finger, and part of the ring finger. (Refer fig. 16) (Fig. 16) Ulnar The ulnar nerve travels through a tunnel in the wrist called Guyon s tunnel formed by two carpal bones and the ligament that connects them together. The ulnar nerve supplies feeling to the little finger and half of the ring finger. (Refer fig. 17) (Fig. 17)
Unit 1: Normal Hand Anatomy Blood Vessels The two main vessels of the hand and wrist are: (Refer fig. 18) (Fig. 18) Radial Artery The radial artery is the largest artery supplying the hand and wrist area. Traveling across the front of the wrist, nearest the thumb, it is this artery that is palpated when a pulse is counted at the wrist. (Refer fig. 19) (Fig. 19) Ulnar Artery The ulnar artery travels next to the ulnar nerve through Guyon s canal in the wrist. It supplies blood flow to the front of the hand, fingers and thumb. (Refer fig. 20) Bursae Bursae are small fluid filled sacs that decrease friction between tendons and bone or skin. Bursae contain special cells called synovial cells that secrete a lubricating fluid. When this fluid becomes infected, a common painful condition known as Bursitis can develop. (Refer fig. 21) (Fig. 20) (Fig. 21)
Unit 2: Dupuytren's Contracture What is Dupuytren's Contracture? Dupuytren s Contracture is a hand condition affecting a patient s ability to straighten the affected fingers. Thickening of the underlying tissues in the palm of the hand affect the tendons ability to move the fingers freely. This leads to a fixed contracture where the affected finger or fingers are bent in towards the palm and the patient is unable to straighten them. It commonly occurs in the ring finger and little finger. Occasionally the middle finger is affected but the thumb and index finger are rarely affected. (Fig. 22) Dupuytren s Contracture is a condition that usually progresses slowly over many years and is not painful. However, some cases progress rapidly and may be painful to the patient. (Refer fig. 22) Signs and Symptoms Commonly reported symptoms associated with Dupuytren s Contracture include the following: Firm lump or knot may appear in palm of hand that may be tender to touch Dimpling or puckering of the palm tissue Thick cord-like tissue may form in the palm of the hand where the tissue has thickened (Fig. 23)
Signs and Symptoms Unit 2: Dupuytren's Contracture (Fig. 23) Finger curls in towards the palm of the hand with inability to straighten Impaired finger function affecting daily activities May occur in both hands Is usually not painful Causes and Risk Factors The cause of Dupuytren s Contracture is unknown. However, there are certain risk factors that may increase your chance of developing the condition. These can include the following: Gender The condition is more common in males than females. Age It occurs more frequently around ages 40. Heredity The condition tends to run in families. Ancestry Most commonly affected are northern Europeans and people of Scandinavian descent. Social Habits Smoking and drinking alcohol may increase your risk of developing the condition Medical Conditions Patients with diabetes, alcoholism, cirrhosis of the liver, and seizure disorders appear to be at increased risk of developing the condition.
Unit 2: De Quervain's Tenosynovitis Diagnosis Hand and wrist conditions should be evaluated by an Orthopaedic hand surgeon for proper diagnosis and treatment. Your surgeon will perform the following: Medical History Physical Examination Dupuytren's Contracture is diagnosed based on the history and physical and without any special testing required. Conservative Treatment Options You may not need treatment for Dupuytren s contracture if the condition is not affecting your ability to perform daily activities. However, if you are experiencing pain or are having difficulty using your hands for everyday activities, your surgeon will recommend conservative treatment options to treat your condition. Treatment options will vary depending on the severity of the condition. Conservative treatment options may include the following: Heat: Applying heat to the palms of the hand prior to massage or exercise can help to loosen the tissues. Massage: Gently massage the thickened tissues of the palm. (Fig. 24) Exercises: Stretching exercises such as bending the fingers away from the palm may be useful. Injections: Steroid injections in the palm may be done to relieve local inflammation.
Conservative Treatment Options Needle Aponeurotomy: This procedure involves inserting a small needle into the thickened palm tissue and manipulating it to loosen and break up the contracting tissue. Ultrasound may be used to guide the needle to avoid hitting nerves or tendons. (Refer fig. 25 to 27) Unit 2: De Quervain's Tenosynovitis (Fig. 25) (Fig. 26) (Fig. 27) Collagenase Injection: An enzymatic drug that breaks down collagen can be injected into the corded tissue to soften and weaken the contracture. The physician then manipulates the tissue manually to break up the tissue. (Refer fig. 28 to 30)
Conservative Treatment Options (Refer fig. 28 to 30) Unit 2: De Quervain's Tenosynovitis (Fig. 28) (Fig. 29) (Fig. 30)
Unit 3: Surgical Procedure Surgical Procedure- Introduction If conservative treatment options fail to resolve the condition and symptoms persist for 6 months or more and your quality of life is adversely affected, your surgeon may recommend you undergo a surgical procedure to open the tendon sheath and allow more room for tendon movement. Surgical Treatment This surgery is usually performed in an operating room under local or regional anesthesia on an outpatient basis as day surgery. Your surgeon makes a small incision to the affected palm area. The surgeon then removes the thickened fibrous tissue causing the contracture. The incision is then closed with sutures and covered with a sterile dressing. (Refer fig. 31 to 34) (Fig.31) (Fig. 32) (Fig. 33)
Unit 3: Surgical Procedure Surgical Treatment (Refer fig. 31 to 34) (Fig. 34) Post Operative Care After surgery your surgeon will give you guidelines to follow. Common post-operative guidelines include: Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering. Ice packs to the surgical area may be used to reduce pain and swelling. The bandage is usually removed after a couple days. (Fig. 35) Your surgeon may recommend occupational therapy for strengthening exercises and measures to prevent recurrence. Eating a healthy diet and not smoking will promote healing.
Unit 3: Surgical Procedure Risks and Complications As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to hand surgery. Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications Includes: (Fig. 30) Allergic reaction to medications Blood loss requiring transfusion with its low risk of disease transmission Heart attack, strokes, kidney failure, pneumonia, bladder infections Complications from nerve blocks such as infection or nerve damage Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death. The majority of patients suffer no complications following Duputytrens Contracture surgery, however, complications can occur following hand surgery and include: Infection Nerve damage causing weakness, paralysis, or loss of feeling in the hand area Injury to the arteries of the fingers/hand Condition recurs
Unit 3: Surgical Procedure Risk factors that can negatively affect adequate healing after surgery include: (Fig. 31)
Unit 3: Disclaimer Summary A good knowledge of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery. Disclaimer Although every effort is made to educate you on Dupuytren s Contracture, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any questions you may have. You must not proceed until you are confident that you understand this procedure, particularly, the complications.
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