DUPUYTREN'S DISEASE: Surgery, needle aponeurotomy or xiaflex?

Dupuytren's Disease 

What is Dupuytren's disease?
Dupuytren’s disease is an abnormal thickening of the tissue just beneath the skin known as fascia. This thickening occurs in the palm and can extend into the fingers (see Figure 1). Firm cords and lumps may develop that can cause the fingers to bend into the palm (see Figure 2), in which case it is described as Dupuytren’s contracture. Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

What causes Dupuytren's disease? The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.
What are the symptoms and signs of Dupuytren's disease?

Symptoms of Dupuytren’s disease usually include lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Thick cords may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. These cords cause bending or contractures of the fingers. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop (see Figure 3). As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets.  Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

What are the treatment options for Dupuytren's disease?
In mild cases especially if hand function is not affected, only observation is needed.
 For more severe cases various  techniques are available in order to straighten the finger(s). Your treating surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved. The goal of any treatment is to improve finger position and thereby hand function. Despite  treatment the disease process may recur. Before treatment, your doctor should discuss realistic goals and results.
Types of treatment may include Needle Aponeurotomy, Partial or Complete Fasciectomy, and limited release as well as on Collagenase injections or cortisone injection in a nodule.  The rationale behind each treatment depends upon the treating physician and the patient.
Surgical Fasciectomy  (Partial or Complete) uses open incisions and the cords and nodules are removed
Open Aponeurotomy or Fasciotomy uses small incisions an the cords are released
Needle Aponeurotomy  (NA) or Percutaneous Aponeurotomy (PA) or Percutanoeous Needle Fasciotomy (PNF) or Incisional Fasciotomy or Open Fasciotomy
Needle aponeurotomy uses a small gauge needle or a microblade as a cutting device to sever the abnormal cords of tissue in the palm and digits which cause the fingers to flex down.  The tissue is not removed it is essentially perforated or cut in multiple places along the palm  to release the contracture (see figure 3) Incisional or Open fasciotomy is done in some instances.
Collagenase Injection (Xiaflex)
Collagenase is an enzyme that digest collagen a structural protein in tissues.  Xiafllex is a collagenase derived  from the bacteria Clostridium Histolyticum.  Xiaflex is a mixture of several types of collagenase, titrated to achieve digestion of  tissue or cords that are present in the hands  of those who have Dupuytren's disease. (Figure 4)
Corticosteroid Injection (cortisone shot)
When a steroid or cortisone injection  is given to the palm, in a nodule or small cord  it will often soften the cord. There are studies that state that this may limit progression of the disease While there have been no large scale prospective double blinded studies or dose dependent sudies many surgeons now will attempt to inject a nodule or soft cord that is not ready for surgery in an attempt to treat it.

IMPORTANT considerations:

1. The presence of a lump in the palm does not mean that surgery  or treatment is required or that the disease will progress.
2. Correction of finger position is best accomplished with milder contractures and contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger. no matter what method is used.
3. Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient during open fasciectomy or open removal of cord tissue..
4. The nerves that provide feeling to the fingertips are often intertwined with the cords and may be affected by any treatment
5. Splinting and hand therapy are often required after surgery  or other treatment procedures in order to maximize and maintain the improvement in finger position and function.
6. All treatments for Dupuytren's may involve the risk of tendon, nerve, joint, skin: injury, infection, and stiffness. as well other conditions that may negatively affect the result.

 
Figure 1: Dupuytrens disease may present as a small lump, pit, or thickened cord in the palm of the hand
 
Figure 2: In advanced cases, a cord may extend into the finger and bend it into the palm

Figure 3: In Needle Aponeurotomy , a cord may be released without the need for  standard  incisions.

Figure 4: , Xiaflex is a collagenase, a drug that is injected into a cord  to dissolve a small segment of that cord, to treat the contracture.
These pictures are before and one day after injection  (just after manipulation). Xiaflex  treatment requires that a manipulation take place the next day

*Based on Phase I clinical trials, collagenase injections work better for metacarpophalangeal (MP) joint contractures than for proximal interphalangeal (PIP) joint contractures, and for lower severity contractures than for higher severity contractures.

*Ideally, patients for collagenase injection should have a well-defined, palpable cord, ideally one that is strung away from the flexor tendon system. The worst patient is probably someone who has a small finger IP contracture that’s more than 50 degrees and has been there for 5 or 10 years. Collagenase can only affect the cord itself; it won’t be able to act on the secondary tissues that have changed. *(source; http://www.aaos.org/news/aaosnow/oct10/clinical2.asp)

More information, references and documents

Dupuytren's Bibliography
Collagenase and Needle Aponeurotomy for Dupuyten's Disease ; a 2010 Article discussing reported date 

Dupuytren's Update NA and Xiaflex 

Dupuytrens   (.PDF)   from ASSH

New treatments for Dupuytren contracture from AAOS

XIAFLEX® CORD II Study Published in The Journal of Hand Surgery

Xiaflex injection photos from AAOS (PDF)

portions © 2009 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee
taken modified from ASSH and other sources including AAOS by www.handctr.com

HALLOWEEN PUMPKIN CARVING SAFETY TIPS (part 2)

Halloween Safety Tips That Are No Trick:  Orthopaedic Surgeons offer Halloween Injury Prevention Tips

Every Halloween, kids across the country parade
 neighborhoods in search of the most glorious prize:
candy.   The build-up for Halloween is almost as exciting as the day itself with pre-Halloween festivities like pumpkin-picking, pumpkin carving and selecting the perfect costume for the big day.  And though the holiday calls for fun, the American Academy of Orthopaedic Surgeons (AAOS) stresses the importance of taking proper precautions to avoid injuries this Halloween.

HALLOWEEN INJURY STATISTICS: A nine-year study examined holiday-related pediatric emergency room visits between 1997 and 2006.  Results of this study show Halloween among the top three holidays producing the most ER visits:

• Finger/hand injuries accounted for the greatest proportion of injuries on Halloween (17.6 percent).
• Of the finger/hand injuries sustained on Halloween, 33.3 percent were lacerations and 20.1 percent were fractures.
• Children ages 10-14 sustained the greatest proportion of injuries (30.3 percent).

Source:  D’Ippolito A, Collins CL, Comstock RD. Epidemiology of pediatric holiday-related injuries presenting to US emergency departments. Pediatrics. 2010 May;125(5):931-7.

for more information :   http://handctr.blogspot.com/2010/10/hand-surgeons-warn-of-pumpkin-carving.html

Hand Surgeons Warn of Pumpkin Carving Dangers

Hand Surgeons Warn of Pumpkin Carving Dangers




Hand Surgeons Warn of Pumpkin Carving Dangers


Use caution during the Halloween season, and take steps to prevent hand injuries when carving.

“Every Halloween season we see four or five patients—both adults and children—who come into our office with severe injuries to their hands and fingers,” says Jeffrey Wint, MD, an ASSH member from The Hand Center of Western Massachusetts, Springfield, MA. “Treatment can often run three to four months from the time of surgery through rehabilitation.”

To prevent hand injuries, the ASSH suggests the following safety tips

Carve at a Clean, Dry, Well-lit Area

Wash and thoroughly dry all of the tools that you will use to carve the pumpkin: carving tools, knife, cutting surface, and your hands. Any moisture on your tools, hands, or table can cause slipping that can lead to injuries.

Always Have Adult Supervision

“All too often we see adolescent patients with injuries because adults feel the kids are responsible enough to be left on their own,” says Wint. “Even though the carving may be going great, it only takes a second for an injury to occur.”

Leave the Carving to Adults

Never let children do the carving. Wint suggests letting kids draw a pattern on the pumpkin and have them be responsible for cleaning out the inside pulp and seeds. When the adults do start cutting, they should always cut away from themselves and cut in small, controlled strokes.

Sharper is not Better

“A sharper knife is not necessarily better because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it,” says Wint. “An injury can occur if your hand is in the wrong place when the knife finally dislodges from the thick skin of the pumpkin. Injuries are also sustained when the knife slips and comes out the other side of the pumpkin where your hand may be holding it steady.”

Use a Pumpkin Carving Kit

Special pumpkin carving kits are available in stores and include small serrated pumpkin saws that work better because they are less likely to get stuck in the thick pumpkin tissue. “If they do get jammed and then wedged free, they are not sharp enough to cause a deep, penetrating cut,” says Wint.

Help for a pumpkin carving injury

Should you cut your finger or hand, bleeding from minor cuts will often stop on their own by applying direct pressure to the wound with a clean cloth. If continuous pressure does not slow or stop the bleeding after 15 minutes, an emergency room visit may be required.

Copyright © American Society for Surgery of the Hand 2009.

modified altered and changed by www.handctr.com from assh.org

see also http://www.handctr.com/Jeffrey%20C%20Wint.htm

http://www.assh.org/Public/Safety/Pages/PumpkinCarvingSafety.aspx

Mallet finger (baseball finger)

MALLET FINGER (BASEBALL FINGER)

A mallet finger occurs when the extensor tendon at the tip of a finger ruptures. The rupture of this tendon can involve the tendon alone, be associated with a small bone fragment or fracture or can be associated with a fracture that requires significant care.

The force applied to the finger can come from something as simple as tucking in a bed sheet or can come from a direct blow to the end of a finger. Mallet finger has also been known as baseball finger.

Mallet finger.

A mallet finger often begins with pain at the distal joint of the finger.  At times there is an immediate loss of motion while at other times the finger seems to stay straight for a while and only later starts to lose its ability to be extended actively at the tip.  At times there is an injuries are typically closed in that the skin and nail is intact but at times there is an injury to the skin or nail bed as well. In severe cases the injury is associated with an open injury to the joint or bone, a so called open or compound fracture.

In adults the injury can involve the joint surface.  In children it can involves the growth plate or physis.

The diagnosis is often made based upon the type of injury and the appearance of the finger.  The fingertip will droop down and there is a loss of active motion.  Often the finger can be passively pushed up to straighten it but the independent active motion to extend the digit at the tip has been lost

X-rays are often taken to further delineate the injury and see how much if any bone, joint or

Types of splints used to treat mallet finger. A, Dorsal aluminum splint. B, Commercial splint.

Reproduced with permission from Culver JE Jr: Office management of athletic injuries of the hand and wrist. Instr Course Lect 1989;38:473-482.

 growth plate is involved

Treatment depends largely upon the extent the soft tissue and underlying boney injury.

Tendon rupture without bone injury

Most of these mallet finger injuries can be treated with splinting.  The splint can be applied in a variety of ways depending upon the injury.  Typically the split is left in place full time for six to eight weeks with a time for part time splinting after that depending upon what daily activity is done by the patient with a typical part time period of 3 – 4 weeks.  In some situations pinning of the joint is used rather than a splint

Tendon rupture with a small bone fragment

These injuries typically are treated like non-boney injuries

Tendon rupture with a large bone fragment involving the joint.

 These injuries may respond to splinting and splinting is often used however a small bump may always be present a t the joint.  At times if the doctor feels that that the bone fragment is large enough and the joint may be unstable surgery may be offered.  During surgery pins or small screws may be used and the joint itself may be pinned to prevent motion during the healing process.

  

Above: X-rays showing fracture at the insertion of the extensor tendon. In the first image on the left the fragment is displaced.  This will heal with a bump but will be able to be treated with a splint.  IN the image on the right the joint has subluxed.  This will  need to have surgical repair.

In adults with severe open injury more immediate surgery may also be offered

Children

In children the doctor needs to differentiate between these injuries that require reduction or realignment of the bone without surgery and those who may have a portion of the nail bed significantly torn or retained within the fracture site or growth plate.  Often children will not have a tendon injury but a fracture through the physis which appears to be a mallet injury.  X-rays often will reveal this.

 

Mallet deformity from a fracture across the growth plate in a child is different than the adult fracture or tendon avulsion

Late or Delayed Treatment in adults

Delayed treatment of mallet finger deformity may consist of splinting initially and at times surgical methods are offered to correct chronic deformities and other associated joint and tendon problems that may accompany the chronic situation

Results

Most mallet fingers heal well, although often there is a slight loss of full extension. The slight extension loss typically has no effect on hand of finger function, but if left untreated it can cause other issues to occur in the finger due to tendon imbalance. While treatment of a closed mallet finger is not an acute emergency, the improper, partial or untreated injury can lead to further problems such as a swan neck deformity.

 Swan neck deformity from tendon imbalance and laxity at the proximal joint.

CNN : Can you really re-grow a fingertip? ... is misleading.

The recent CNN report about a woman's fingertip regenerating is misleading. As a hand surgeon I have treated hundreds of these injuries with serial dressing changes and little else. For an orthopedic surgeon or a hand surgeon this type of injury and its typical treatment is as basic as taking care of a non-displaced fracture or treating carpal tunnel syndrome.  This was an unfortunate injury, but the result is as expected. In this case it appears that there was not any tissue regeneration. The skin healed over the bone but no length was added. If you look closely at the photos, the fingertip shortening is equivalent to the length of the lost tissue. The original injury had a small part of the nail plate attached to skin and fat. The nail grew out past the residual skin but the skin and fat never regenerated any lost length. The story is misleading. While great credit is due to the researchers for their work. In this scenario the product cited is not going to make a significant difference. Please read the readers comments in the blog from the CNN followup story. (and look closely at the fingertip photos)

Can you really re-grow a fingertip?

pagingdrgupta.blogs.cnn.com

On a normal day, Dr. Stephen Badylak’s office at the University of Pittsburgh receives five or six e-mails requesting help from people who’ve lost various body parts, particularly fingertips or toe tips.

QR for Dr. Wint

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FW: lawnmower safety for kids

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LAWNMOWERS CAN BE DANGEROUS TO YOUR HEALTH

Devastating accidents to the hand and fingers can occur when used improperly

SPRINGFIELD- Every summer, lawnmowers are constantly running as homeowners try to keep their yards trim and beautiful. Unfortunately, “lawnmowing season” brings many people, especially children, with devastating hand injuries to emergency departments such as Baystate Medical Center.

            According to the American Society for Surgery of the Hand, every year more than 74,000 small children, adolescents and adults are injured by rotary, hand and riding power mowers due to the improper handling of lawnmowers.

            “Every summer we see patients, both adults and children, who come into our office with severe injuries to their hand and fingers,” said Dr. Jeffrey Wint of the Hand Center of Western Mass.

“Often parents will give their children a ride on the lawnmower as a treat, but this can be very dangerous, as kids can fall off and get injured. Adults who attempt to maintain mowers without taking proper safety precautions often get injured, too,” added Dr. Wint, who is a member of the medical staff at Baystate Medical Center.

  According to Dr. Wint, 20 percent of lawnmower injuries are to the hand, wrist or fingers and about 25 - 50 percent of those injuries result in amputation. He noted that injuries from lawnmower accidents can be devastating and extremely hard to treat.

“Injuries can become contaminated from soil or dirt from the mower, which can lead to serious infections resulting in amputations,” Dr. Wint warned.

Most injuries can be avoided by using common sense and practicing safe mowing. To stay safe while mowing:

      Never allow children to operate the machine.

n       Children under age 6 should remain indoors when the lawn is being mowed.

Be alert and turn machine off if a child enters the area.

Tragic accidents can occur if the operator is not alert to the presence of children. Children are often attracted to the machine and the mowing activity. Never assume that children will remain where you last saw them

n       Safety training is essential for those old enough to operate a lawnmower.  Supervise your children     until you are satisfied they understand how to safely operate the mower and can manage the task alone.

n       Never service mowers while in operation and always keep them in good working order.

n       Do not use hands or feet to clean mower, especially around the blade, because even with the mower off, there can still be tension on the blade, which can spin rapidly once cleared. Always use a stick or broom handle to remove any obstruction

n       When mowing a slope with a walk-behind mower, mow across the face of the slope, not up and down.

n       When using a riding mower, go up and down the slope rather than across to avoid tipping over.

n       Read mower's instruction manual and do not remove safety devices or guards.

Do not mow in bad weather, in poor light, or on wet grass.

Use extreme care when approaching blind corners, shrubs, and trees, or other objects that may block your view of a child.

      Never allow passengers, other than the operator, on riding mowers.

Never carry children, even with the blade(s) shut off. They may fall off and be seriously injured or interfere with safe mower operation. Children who have been given rides in the past may suddenly appear in the mowing area for another ride and be run over or backed over by the machine

n       Do not operate lawnmower while barefoot and wear gloves, long pants and goggles.

          

  Parents need to remember that lawnmowers are not toys and must be used appropriately. Many children have died from accidents on or around mowers. Dr. Wint warns that lawnmowers can be “a potential lethal weapon and just as dangerous as giving a child a loaded gun.”

Wint cites the American Society for Surgery of the Hand which offers these revealing figures:

Kinetic energy (motion) imparted by a standard rotary blade is comparable  to three times the muzzle energy of a .357 Magnum pistol. Blade speed can eject a piece of wire or an object at speeds up to 100 miles per hour.

He said there is a need to create an awareness of the potential dangers of lawnmowers, as many of the accidents are preventable.

“It is heartbreaking to see some of these children’s injuries,” said Dr. Wint. “Remembering these few safety precautions and using sound judgment can keep everyone safe and lawns looking great this summer.”

                                              

Needle Aponeurotomy Massachusetts

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Needle Aponeurotomy for Dupuytren's Contracture ... The Hand Center or Western Massachusetts is the only medical practice in Western Massachusetts dedicated to the care of the hand and upper extremity.

Use caution when using snow blowers

Updated: Wednesday, 09 Dec 2009, 9:39 PM EST
Published : Wednesday, 09 Dec 2009, 7:43 PM EST

• Lynn Barry

With the first significant snowfall here, people should use extreme caution when using snow blowers.

Each year, 5,000 people in this country suffer a hand injury from using a snow blower. Some of those injuries can be severe like losing a finger.

Hand surgeon, Dr. Jeffrey Wint of the Hand Center of western Massachusetts says if you're snow blower jams, turn it off and never put your hands or feet in the intake or outtake.

If you have a snow blower that has a clutch, disengage the clutch. Then wait or delay about 10-15 seconds because it takes time for the machine to calm down and then use a stick.

Dr. Wint also said that 500 people each year lose a finger as a result of a snow blower injury.

Recommendations for safe use of a jammed snow blower snow blowers include : (OCD STICK)

1. If the snow blower jams, immediately turn it OFF

2. Disengage the CLUTCH

3.DELAY.. Wait 10 seconds after shutting of to allow Impeller Blades to stop rotating

4. Always use a STICK or broom handle to clear impacted snow. The stick most be strong enough to avoid breakage or eye injures can result from flying fragments

5. Never put your hand near chute or around blades

6. Keep all shields in place. Do not remove safety devices on machine

7. Keep hands and feet away from moving parts

8. Keep a clear head, concentrate and ...

Do not drink alcoholic beverages before using a snow blower

As physicians dedicated to the care of the Hand and Upper extremity we want to inform the public concerning the perils and pitfalls of improper snow blower use. Physicians, nurses, allied health professionals and therapists who deal with these injuries live in fear of the first heavy wet snow of the season. Invariably injuries are seen despite general knowledge that these injuries occur. These safety tips cannot guarantee against injury but hopefully if you are reading these or even better spreading these... it is one more step towards preventing these types of injuries.

News organizations and weather services can help.

Conditions that are associated with a higher incidence of injuries, hay wet snow exceeding 6 inches of accumulation and temperatures above 28 degrees Fahrenheit offer good opportunities to provide warning for the public. We need your help to reduce the incidence of these preventable injuries.

Patient's Choice Award 2009

Dr. Jeffrey Wint has been honored by his patients with a Patients' Choice Award for 2009. Every month, over 40,000 patients rate the effectiveness of their physicians online at www.vitals.com. Of the nations 720,000 active physicians, less then 5 % were accorded this honor by their patients in 2009.

www.handctr.com

Endoscopic Surgery Speeds Recovery for Patients with Carpal Tunnel Syndrome print this page email to a friend The bane of data processors, carpenters, musicians, lumberjacks -- anyone whose job requires frequent, repetitive bending of the wrist -- carpal tunnel syndrome has been called the "new industrial epidemic." Although the prevalence of the condition is not known, the National Institute of Occupational Safety and Health reports that 15 to 25 percent of workers employed in construction, food preparation, clerical work, production, fabrication and mining are at risk for cumulative trauma disorders like carpal tunnel syndrome. The traditional surgical treatment for the condition required an incision in the palm. While this procedure successfully relieved the wrist pain, tingling and numbness that characterize carpal tunnel syndrome, it often created incisional problems. The location of the incision increased the chances that small nerve branches in the hand might be cut, producing discomfort in the scar. Thanks to a new surgical procedure used at Baystate Medical Center, many of these problems are being eliminated. Baystate hand surgeons are the first in the area to utilize endoscopic surgery to treat carpal tunnel syndrome -- a technique that markedly reduces the size of the necessary incision, resulting in a faster recovery and, for many patients, a more rapid return to work. "Although carpal tunnel surgery has been performed successfully for years, some of the minor problems associated with the open-palm method have prevented patients from receiving the full benefit of the procedure," says Jeffrey C. Wint, M.D., an orthopedic hand surgeon at Baystate who uses the endoscopic technique. "For people who work with their hands, the time spent recovering from a major incision in their palm can be a significant setback." Causes and Cures Carpal tunnel syndrome arises when repetitive wrist motion causes swelling of the tissues within the carpal tunnel. The transverse carpal ligament is unyielding and the median nerve is compressed. The initial symptoms are wrist pain and a tingling sensation in the fingers, usually felt when the hand is at rest. If not corrected, the condition can produce numbness and weakness throughout the hand, making simple tasks such as holding a newspaper or turning on a faucet painful or impossible. Surgery has been able to alleviate these symptoms by cutting the ligament that overlies the median nerve at the juncture of the wrist and hand. Until recently, however, the only means of access to the ligament has been through an incision in the palm.