Scott W. Wolfe, MD performs a demonstration of the volar approach for PIP
joint implant arthroplasty on a right hand.
First heralded by a thickened nodule in the palm or a tight band tethering a finger, Dupuytren’s Disease is a common genetic disorder that can progressively impair hand mobility and function. It is more common in men, but women may have a particularly aggressive involvement.
The disease may be staged by its severity and corresponding treatment options. In general, the stages are progressive, and involve fewer individuals in the more advanced stages. Dr. Wolfe has over 26 years of experience in treating hundreds of patients in each stage of the disease using a variety of methods, and, when needed, a combination of methods.
Dr. Wolfe and his colleagues at HSS participated in the first FDA trials of a revolutionary and effective new treatment for Dupuytren’s Disease that releases the contracture without surgery. An enzyme (collagenase) is injected into the affected area in the office and the contracture or “cord’ is broken a day or two later by gentle manipulation. This short and non-surgical procedure is done under a local anesthetic to insure a minimum of discomfort. Patients begin to use their hand within minutes of the procedure. Dr. Wolfe and his colleagues at HSS have refined the technique with hundreds of patients to minimize pain and associated risks of nerve or tendon injury.
Clinical staging system and treatment alternatives
Stage I(nascent): A solitary firm nodule or subtle thickened cord is identified in the palm. The fingers are not contracted. A nodule is most frequent at the base of the ring finger, and may be uncomfortable or occasionally painful with activities such as weight lifting, hammering, golf or tennis that require a firm grip. A cord differs from a nodule and is recognized in this stage as a firm, linear thickening within the palm that may be mistaken for a tendon. These cords generally run in the direction of the fingers, and may be tight when stretching the hand. In many affected individuals, there may be an additional thin cord crossing the thumb web space in the palm. The condition may appear spontaneously, or may arise after an episode of hand or wrist trauma, or even after hand or wrist surgery. It often progresses very slowly or not at all, but deserves to be measured and watched every 3-6 months for progression.
Treatment: Stage I rarely requires treatment, but an examination by a hand specialist is important to confirm the disease, define its extent and identify risk factors for progression (Table I). Presence of several risk factors makes it more likely that this stage will progress to contracture and may even spread to uninvolved fingers. Solitary nodules may respond to a series of corticosteroid injections performed in the office. Collagenase (Xiaflex) does not generally improve nodules in Dupuytren’s Disease, and may be ineffective at treating minor cords that do not contract the finger. Surgery is not indicated without a contracture.
Table I. Risk factors for progression
- Strong family history of Dupuytren’s disease
- Onset at a young age
- Involvement of both hands
- Rapid worsening
- “Ectopic” disease (disease in other areas [soles of feet, knuckles, penis])
Stage II (simple): The nodules have linked to become a thickened and solitary “cord” that stretches across the palm into the finger, causing a tethering or a contracture of the digit (Figure 1). The ring and small fingers are most commonly involved, but any finger can be affected. The condition is not generally painful, but progressive involvement of the MPJ (the set of knuckles closest to the palm) can cause increasing difficulties with daily activities, sports and work. There may be a “daughter cord” branching off the main cord to a neighboring, and usually less severely involved finger. The disease may appear to be contracting the PIP joint (the next-to-last joint on the finger), but in this stage, the PIP joint can always be straightened manually, provided the MP joint is bent towards the palm.
Figure 1A-B. Stage II disease, recognized by an MPJ cord contracting the middle finger but sparing the PIP joint.
Stage III (complex): The disease has extended across the finger to involve the PIP joint (the next-to-last joint on the finger); or has arisen exclusively as a contracture of the PIP joint and spares the palm. Several digits may be involved to a variable extent. The characteristic finding of this stage is that the PIP joints cannot be straightened in any position of the fingers. Occasionally, even the DIP joint (the last joint, next to the nail) is contracted as well. This stage is complex for several reasons:
- A “fixed” contracture of the PIP joint implies the ligaments around that joint have become involved in the disease, and have developed a secondary contracture of their own, and
- Collagenase (Xiaflex™) has a higher reoccurrence rate at the PIP joint, may not be effective at overcoming the secondary contracture of the joint, may make any future surgery more difficult, and
- The cord may be entwined around the nerves and vessels of the finger, or may lie behind the nerves and vessels, hindering access with either collagenase or surgery.
Figure 2. Stage III disease; note the contracture of the MPJ and PIP joints.
Treatment (stage III): Fixed and severe contractures of the PIP joints (figure 2) are generally treated with open surgery to ensure the most complete correction and the lowest chance of recurrence. Collagenase injections may help to gain some improvement and may provide temporary relief when open surgery is impractical or too risky because of other health conditions. Splinting and hand therapy offer little relief at this stage.
Stage IV (complicated): The disease involves both the MPJ and PIP joints of several digits of both hands, and the patient may have most or all of the risk factors for progression (Table I). Other examples of complicated cases include recurrence after previous surgery, because it adds a potential incisional contracture, as well as surgical scar around the joints, nerves and vessels. Dupuytren’s disease can also be complicated when it is present with another injury, such as a fracture, laceration or pulley rupture. Occasionally, neglected or late Dupuytren’s disease can present with fixed contractures of the fingers so that the fingers are folded down into the palm and cannot be extended. Severe contractures involving the PIP joints can stretch or rupture the tendons responsible for straightening the finger, upsetting the very fine tendon balance and causing a paradoxical extension deformity of the DIP joint.
Figure 3. Stage IV (complicated) disease with severe (90 degree) fixed PIP contracture, previous surgical scarring, MPJ contracture and pulley disruption.
Treatment (stage IV): Customized and frequently combined treatment modalities may be necessary for complicated cases with severe contracture. In addition to open surgery, Dr. Wolfe may occasionally employ an external device that uses rubber bands to gradually stretch the diseased tissue and contracted ligaments (the Digit Widget™) (Figure 4). Skin grafts are employed when the native skin is deficient, severely involved in the disease, or compromised by previous interventions. Collagenase can also be used to initially break the palmar bands in a staged procedure, allowing Dr. Wolfe access to the more complicated PIP joints.
Figure 4. Same patient from figure 3 several weeks following release and application of Digit Widget.
Figure 5. Combined treatment of complex contractures using open surgery, skin graft and digit widget application for the ring and small fingers
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Forearm: Ulnar Impaction Syndrome
Who would think that just a two millimeter variation in the length of the two forearm bones could cause intense pain and impairment with everyday activities? When playing racquet sports, not only is the top spin of a forearm shot excruciating, but simply lifting a gallon of milk from the refrigerator becomes an almost impossible task. The disorder is called Ulnar Impaction Syndrome, and it most commonly affects young and active individuals. Repeated impaction of the longer ulnar bone against the small wrist (or carpal) bones creates cumulative damage to the bones and soft tissues about the distal radio-ulnar joint, (insert image), the triangular fibrocartilage, and the carpal bones.
Recreational and professional athletes can be temporarily sidelined by the recurrent pain and swelling of this condition. Patients may be treated for months with various splints, injections and anti-inflammatory medications. Dr. Wolfe diagnoses the condition with a thorough examination of the wrist and forearm, and confirms the diagnosis with plain radiographs and the pronated grip film of each wrist (insert image). On occasion, an MRI scan (insert image) is helpful to demonstrate involvement of other bones or to rule out other diagnostic possibilities such as DRUJ arthritis, TFCC detachment and radial-ulnar-instability.
While several surgical techniques have been utilized to treat the disorder, Wolfe and his colleagues published successful results of their technique for ulnar shortening osteotomy a decade ago. Their method has a zero incidence of nonunion and excellent success in relieving the pain of ulnar impaction syndrome. They will publish their larger, comparative experience of a technical refinement that further reduces complications and nearly eliminates the need for suture or hardware removal.
Dr. Wolfe treats a wide range of hand conditions. If you do not see yours
listed, please call his office to discuss your individual needs. Dr. Wolfe
has particular expertise in treating:
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Dr. Wolfe’s Publications for Patients
Dr. Wolfe’s Publications for Professionals