Upper Limb Orthotics/Dupuytren's Contracture

Dupuytren’s contracture is a progressive fibroproliferative condition responsible for the progressive development of severe contractures of the fingers and hand (Townley, Baker, Sheppard, & Grobbelaar, 2006). It is also known as the Vikings disease, due to its high prevalence in areas of Viking colonization throughout Northern Europe, and in Northern European descendants living in other parts of the world (Flatt, 2001; Gudmundsson, Arngrimsson, Sigfusson, Bjornsson & Jonsson, 1999). Dupuytren’s contracture appears more frequently, earlier (48±15 years) and more severely in men than women (McFarlane, 1991, pg. 775). It is a debilitating disease that without treatment will continue to progress, eventually rendering the hand either partially or wholly dysfunctional.

The contractures associated with Dupuytren’s are a result of fibroplasia of the finger and palmer fascia, thick bands and nodules grow around the tendons inhibiting range of motion of the joints within the hand and fingers (Bains, 2003; Townely, Baker, Sheppard & Grobbelaar, 2006). Bains (2003) suggests that the contracture of these bands and nodules may be caused by myofibroblasts, which are contractile cells that primarily play a role in wound contraction throughout the body (pg. 793). As the bands and nodules grow they become attached to tendon sheaths, joint capsules and skin (Childs, 2005). These bands and nodules can then contract, due to this; range of extension in the metacarpophalangeal and proximal interphalangeal joints is reduced, this contracture will often continue until hand function is completely compromised.

There are many condition associated with Dupuytren’s contracture that may render a person more susceptible to developing contractures, conditions such as alcoholism, smoking, diabetes, HIV and epilepsy. However it is also noted that a person must have a genetic predisposition to Dupuytren’s for these associated conditions to trigger the development of contractures (Townley, 2006; Childs, 2005). There is some evidence to suggest that a single injury to the hand of a genetically susceptible person could prompt the development of Dupuytren’s. According to McFarlane, (2001) there is little evidence to suggest that manual work will trigger or accelerate development of Dupuytren’s contracture, this however is contradicted by Gudmundsson et al., (1999) who in their study found a significant correlation between manual work and Dupuytren’s development (pg. 294). Regardless of the Dupuytren’s trigger, assessment and treatment will be necessary.

Assessment of Dupuytren’s contracture in the hand is complimented with a grading system to guide treatment and allow accurate communication between clinicians and surgeons. Towney, (2006) and Brenner et al., (2003) both discuss a grading system for Dupuytren’s contracture, Towney, (2006) describes three stages, early, active and advanced, however Brenner et al., (2003) describes six. These six stages range from stage 0 that exhibits no extension restriction and no lesions; stage N suggesting the presence of a nodule but no contracture; and stages 1 to 6 describe a range of extension deficit from 45 degrees or less to complete contracture of 135 degrees or more as seen in stage 6 (pg. 67). Correct assessment and grading is very important in selecting the most appropriate and least invasive treatment for a patient.

There are many potential treatments for Dupuytren’s contracture both non-operative and surgical depending on stage and individual presentation. Non-operative treatments include pharmacological intervention, corticosteroid and enzyme injections, physiotherapy and splinting. Operative treatments can include either limited or radical fasciectomy, which is the removal of affected fascia, dermofasciectomy that is similar to a fasciectomy however the overlying adhered skin is removed with the fascia, and a slightly less invasive needle fasciotomy where the offending cords are divided (Worrell, 2012). Flatt (2001) makes a statement indicating that although surgery can relieve contractures it does not halt the progression of Dupuytren’s (para, 49), and with that being said reoccurrence is a common event (Kelmer et al., 2012; Worrell, 2012). Regardless of the method used to release contractures, the role of post treatment splinting remains very important (Worrell, 2012; Townley, 2006; Brenner et al., 2003).

Post fasciectomy orthotic treatment initially comes in the form of a immobilizing plaster cast. The cast should hold the hand in the intrinsic plus position with slight abduction of the fingers to reduce the risk of edema, and trim lines should reach the distal phalanges (Brenner et al., 2003). Plaster is a suitable splinting material post surgery as it is cheap, easy to apply and can account for limb volume changes due to dressings, bandages and swelling.

After the initial five-day plaster cast immobilization, a low temperature thermoplastic static extension night splint is advocated (Brenner et al., 2003). The initial purpose of an extension night splint is to hold the metacarpophalangeal joints and the proximal interphalangeal joints in as much extension as possible whilst avoiding stressing wounds (Jerosch-Herold, Shepstone, Chojnowski, Larson, Barrett, & Vaughan, 2011). This extended position of the phalanges and hand places scar tissue under extended low load force, this is in an attempt to encourage favorable scar remodeling (Larson, & Jerosch-Herold, 2008). The advantage of using low temperature thermoplastic over high temperature is that after the wound has healed the low temperature splint could easily be remolded to achieve an increase in joint extension and therefore maintain the surgically obtained extension (Jerosch-Herold et al., 2011). Brenner et al., (2003) also recommend the use of dynamic splinting during the day. Dynamic splinting of the hand allows for controlled active movement of the joints and muscles, which is significant in preventing loss of range of motion due to prolonged immobilization of the hand and or fingers. There are many dynamic splint designs, and are individually tailored to meet the desired functions and orthotic goals of each patient. Using a carefully controlled combination of static and dynamic splints should counter the negative effects of immobilization, and facilitate desirable healing and reduction of contractures.

The effectiveness of postoperative splinting after Dupuytren’s contracture release is still not proven. There is little formal evidence to support the theory that postoperative splinting helps prevent contracture from reoccurring. A randomized control trial by Kemler, Houpt, & van der Horst, (2012) concluded that there was insufficient evidence to suggest that splinting either short or long term postoperatively will reduce the reoccurrence of flexion contractures in the fingers. This view is supported by Jerosch-Herold et al., (2011) who’s trial also concluded there was no statistically significant difference in degrees of extension achieved by night splinting between their intervention and the control groups. Possibilities for lack of splinting effect were cited, one of which was possible insufficient tension provided by the splint. There was no indication whether the authors believed that it was excessive flexion and or strength of the material failing, or if perhaps it was insufficient strapping and application of force within the devices that was contributing to the lack of result. This issue highlights the importance of correctly selecting the type of materials, when splinting the hand after contracture. For instance, low temperature thermoplastic is highly suited to post operative splinting as it is lightweight, re-mouldable, quick and easy to apply, and does not require casting a negative mould. It does however have far less strength than high temperature thermoplastic, particularly in areas of flexion, “any material that can be bent easily with the hands can be deformed easily by the force it is carrying.” (Colditz, 1983, p. 184). This issue can be overcome however by careful splint design and re-enforcing high stress areas. High temperature thermoplastics are a thicker, stronger plastic and will provide a more ridged base of support. Its combined rigidity and durability would make it a more suitable material for construction of a splint for long-term use.

Orthotic treatment of post surgery fasciectomy requires high attention to detail as orthotic prescription changes, as time and healing progress. This dynamic treatment pathway needs to be carefully combined with patient satisfaction and comfort, particularly in relation to night splinting, as compliance can be a major factor in the device reaching its orthotic goal. Whilst credible evidence might be lacking in support of the benefits of post Dupuytren’s contracture release splinting, the overwhelming evidence advocates the almost mandatory use of splints. Until such time as more thorough research is undertaken disproving the assumed benefit of this type of splinting, it will continue as a standard element of the post surgery treatment plan.

References:

Bains, W. (2003). Vasoprotective VEGF as a candidate for prevention of recurrence of fibrotic diseases such as Dupuytren’s contracture. Medical hypotheses, 60(6), 793-796.

Brenner, P., & Rayan, G. M. (2003). Dupuytren's disease: a concept of surgical treatment. Springer.

Childs, S. G. (2005). Dupuytren's disease. Orthopaedic nursing, 24(2), 160-16

Colditz, J. C. (1983). Low profile dynamic splinting of the injured hand. The American Journal of Occupational Therapy, 37(3), 182-188.

Flatt, A. E. (2001). The vikings and Baron Dupuytren's disease. Proceedings (Baylor University. Medical Center), 14(4), 378.

Gudmundsson, K. G., Arngrı́msson, R., Sigfússon, N., Björnsson, Á., & Jónsson, T. (2000). Epidemiology of Dupuytren's disease: clinical, serological, and social assessment. The Reykjavik Study. Journal of clinical epidemiology, 53(3), 291-296.

Jerosch-Herold, C., Shepstone, L., Chojnowski, A. J., Larson, D., Barrett, E., & Vaughan, S. P. (2011). Night-time splinting after fasciectomy or dermo-fasciectomy for Dupuytren's contracture: A pragmatic, multi-centre, randomised controlled trial. BMC musculoskeletal disorders, 12(1), 136.

Kemler, M. A., Houpt, P., & van der Horst, C. M. A. M. (2012). A pilot study assessing the effectiveness of postoperative splinting after limited fasciectomy for Dupuytren’s disease. Journal of Hand Surgery (European Volume), 37(8), 733-737.

Larson, D., & Jerosch-Herold, C. (2008). Clinical effectiveness of post-operative splinting after surgical release of Dupuytren's contracture: a systematic review. BMC musculoskeletal disorders, 9(1), 104.

McCombe, D. (2004). Dupuytren's Disease− A Concept of Surgical Treatment.ANZ Journal of Surgery, 74(9), 753-753.

McFarlane, R. M. (1991). Dupuytren's disease: relation to work and injury. The Journal of hand surgery, 16(5), 775-779. Townley, W. A., Baker, R., Sheppard, N., & Grobbelaar, A. O. (2006). Dupuytren's contracture unfolded. BMJ: British Medical Journal, 332(7538), 397.

Worrell, M. (2012). Dupuytren's disease. Orthopedics, 35(1), 52-60.

Functional Aims and Goals
POP Cast: A POP cast would be applied to the anterior surface of the hand and be secured posteriorly with bandages, primarily after surgical procedures such as a fasciotomy or dermofasciectomy. The aim of the cast is to immobilize the hand across the MC, PIP and DIP joints maintaining the surgically achieved degree of extension in the fingers. A POP cast will also protect surgical wounds from knocks and bumps and help to prevent contracture in the early stages of healing. As swelling, heavy dressings and padding are likely at the surgical site, a POP cast can easily and cheaply be used to accommodate these extra volumes. A POP will mainly be used as an intermediate splint, with a goal of maintaining hand position until such time as healing is sufficient for a definitive device to be custom made and fit.

Low Temperature Thermoplastic: A low temperature thermoplastic hand splint would be utilized around 10 – 14 days after surgery, this allows for wound healing and swelling subsidence. The aim of a thermoplastic splint is to help maintain the surgically achieved degree of extension across the affected joints of the fingers; this is achieved by using three points of pressure in the application of force. The goal of a definitive low temperature thermoplastic splint is to be sufficiently comfortable, to encourage compliance, and to protect as best as possible against reoccurring contracture and allow desirable remodeling of tissues to a more functional state.

Manufacturing process
Night Splint Design With the aim of maintaining surgically obtained extension of the MCP, PIP and DIP joints, a splint was designed to intimately fit the anterior surface of the affected hand Figure 1. The drawing in Figure 2. Shows the distal, proximal and thenar trim lines. The distal trim line ends just beyond the tip of the 3rd phalange and the proximal trim line ends level with the pisiform. The proximal trim line is positioned to allow free movement of the wrist, and the thenar trim line is well rounded, smooth and sufficiently clear of the thumb to allow opposition and flexion. supporting (in this case) 45° of flexion. To reduce the risk of high pressure points and provide counter force against contractures, the splints design incorporates a large surface area across phalanges 2-5 and over the palmer surface excluding the thenar eminence. The lateral and medial trim lines along the length of the fingers curve anterior to posterior to approximately 3⁄4 the depth of the fingers. Figure 1. shows the initial drawing of the basic shape of the device, demonstrating the medial and lateral trim lines with the intended purpose of safely containing the fingers and adding rigidity to the device. All trim lines are rolled or smoothed over to ensure there are no rough edges. Figure 2. Figure 3. Figure 4. shows the three points of pressure applied in this splint. The use of low temperature thermoplastic is important in this post operative splint as frequent adjustments may be necessary to slowly decrease the angle of flexion or adjust for swelling. A definitive night splint could be constructed with the same design but using a ridged high temperature thermoplastic after the healing and adjustment period is over. Figure 4. The straps are added in Figure 3 and are positioned in such a way to facilitate suspension and to provide the relevant force across the joints of the hand. The straps are board, soft, and enable easy and quick donning and doffing. Manufacturing Process Materials: • Low temperature thermoplastic • Chux or paper • Velcro strips, loops and self adhesive hooks • Low density, soft foam • Contact adhesive Figure 5. 3. Trace the template on a sheet of thermoplastic and cut out the design. 1. Trace the hand on a piece of paper or Chux cloth, marking the MCP, PIP joints. 2. Draw the shape of the splint around the tracing of the hand allowing sufficient overlap to allow for rolling of the edges and folding the medial and lateral edges over the sides of the hand as shown in figure 5 then cut out the template and test for sizing on the clients hand. Figure 7. Figure 6. Figure 8. 4. Place the thermoplastic template into a water bath set at approximately 60° - 70° until it becomes soft and tacky. 5. Position the client so they are comfortable preferably seated with their elbow supported on the bench. 6. Carefully remove the now soft plastic from the water bath and check its temperature to ensure it is not too hot for skin contact. 7. Position the plastic over the anterior surface of the hand and carefully mold into position. Working quickly, position the hand to achieve the desired degree of flexion at the MCP, PIP and DIP ensuring all fingers are in correct position before the plastic hardens. 8. Carefully roll the edge along the thenar cut out and continue on around the proximal trim line creating smooth edge. 9. Check all trim lines for length, height and fit, and cut away any excess before the plastic completely hardens (remove the device from the client before trimming). 10. Using the heat gun or water bath to soften the plastic, gently smooth or roll the remaining rough edges being careful not to deform the shape of the device. Figure 9. 11. Measure the length of the loop Velcro strapping needed to span the wrist and the back of the hand and cut 3 lengths of broad Velcro and one piece slightly more narrow. Round off one end of the Velcro to create a neat finish. 12. To attach the straps mark on the device the location of fixation for the straps, then using a heat gun, carefully warm the attachment point for the Velcro on the plastic. Once it is tacky, heat the fluffy side of the rounded end of the Velcro until it is slightly melted then press it on to the tacky surface of the device. Test the angle of attachment is correct, if not remove the strap and try again. Figure 10. 13. With all straps attached, cut some small sections of the hook side of the Velcro and trim them to appropriate shape for anchoring each strap. Repeat the attachment process as above however heat the self-adhesive side of the Velcro not the side with the hooks. Check fit of device with straps done up and trim excess strapping rounding the edges for a smooth finish. Figure 11. 14. Cut two pieces of soft low-density foam the same length and roughly 2cm wider than the wrist and the MCP straps. Round the ends of the foam (as seen in Figure 12.). Make a cut the width of the strap in either end of the foam leaving approximately 1cm overlap on each side of the strap. When happy with positioning of the foam, glue the ends down with contact adhesive. 15. Check fit. Figure 12.

Critique of fit
The Client: Patient is a 53-year-old male, presenting two weeks post fasciectomy to release Dupuytren’s contracture, affecting the right hand and 5th, 4th, 3rd and 2nd phalanges. Night splinting with low temperature thermoplastic is now required to maintain surgically obtained extension of the fingers and assist favourable scar remodelling. The splint may also need to be adjusted by increasing the degree of extension over time in an attempt to promote further range of motion within the fingers and hand. Surgery wounds are healing well and uneventfully.

Subjective assessment: The client has stated that he is very happy with the outcome of the operation thus far and is excited to receive thermoplastic splinting instead of POP. He has reported that he has little pain but he is still wary about knocking his hand during the night. He also reported that his hand gets hot and sweaty and that the POP casts would get smelly very quickly. He would like a device that is comfortable, that will protect his hand, is not too hot, and that can be easily cleaned.

Objective assessment: The objective assessment revealed: •	Good wound healing, only minor dressing necessary •	DIP and PIP joints have achieved full extension •	MCP joints 2nd-5th are to be maintained at 45 degrees flexion •	Thumb moves within normal ROM •	Wrist flexion/extension, ulnar/radial deviation is normal •	Skin appearance and feel is normal (ignoring wound site) •	No sign of sensory loss •	Contralateral limb is unaffected and within all normal ranges, and has good dexterity for donning and doffing the device.

Orthotic goals: To hold the metacarpophalangeal (MCP) joints and the proximal interphalangeal joints (PIP) in as much extension as possible (Jerosch-Herold, Shepstone, Chojnowski, Larson, Barrett, & Vaughan, 2011), and place scar tissue under extended low load force, this is in an attempt to encourage favorable scar remodelling (Larson, & Jerosch-Herold, 2008). The advantage of using low temperature thermoplastic over high temperature is that after the wound has healed the low temperature splint could easily be remoulded to achieve an increase in joint extension (Jerosch-Herold et al., 2011), and can be easily wiped clean or washed if necessary.

Prescription: A splint was designed to intimately fit the anterior surface of the affected hand supporting (in this case) 45° of flexion. To reduce the risk of high pressure points and provide counter force against contractures, the splints design incorporates a large surface area across phalanges 2-5 and over the palmer surface excluding the thenar eminence. The lateral and medial trim lines along the length of the fingers curve anterior to posterior to approximately ¾ the depth of the fingers. The distal trim line ends just beyond the tip of the 3rd phalange and the proximal trim line ends level with the pisiform. The proximal trim line is positioned to allow free movement of the wrist, and the thenar trim line is well rounded, smooth and sufficiently clear of the thumb to allow opposition and flexion. All trim lines are rolled or smoothed over to ensure there are no rough edges. The straps are positioned in such a way to facilitate suspension and to provide the relevant force across the joints of the hand. The straps are board, soft, and enable easy and quick donning and doffing.



Device Presentation:

The splint I created does meet the prescription design: •	The prescribed angle of 45° at the MCP has been achieved along with full extension the DIP and proximal interphalangeal (PIP) joints. •	The wrist can achieve a full range of motion, uninhibited by the proximal trim line. •	Flexion and extension of the fingers is suitably restricted and the construction and material is rigid  enough to resist any contractures. This strength is primarily due to the height and shape of the medial and lateral borders as can be seen in Figure 1. This reduces need for ‘doubling up’ of material to increase strength across the anterior surface. •	Pressure is distributed well throughout the anterior surface of the hand and fingers.

Client fit: •	The device fits the client well, and was reported as being “very comfortable”. •	The fingers sit just inside the distal trim line and are well protected. •	The medial and lateral trim lines are high enough to contain the fingers and add rigidity to the device. •	The thenar trim line provides sufficient clearance to achieve almost full range of motion of the thumb. •	The proximal trim line ends about level with the pisiform and does not appear to rub or interfere with the wrist joint. •	All edges have been rolled or smoothed to ensure no rough or sharp edges. •	Straps apply force over the wrist MCP, PIP and just proximal to the DIP and appear to apply the correct force system.

Areas not meeting the standard: •	The MCP joint strap could be broader to ensure it cannot slip out of place during sleep. •	In an attempt to keep the device neat I was a little too conservative with the size of the Velcro hooks, this could lead to strapping coming undone. Larger pieces of Velcro at attachment points would help correct this problem. •	I have put foam padding over the wrist and MCP joint straps, however I should have padded all straps to increase comfort. Also the edges on the foam are not as neat as they could be and a little glue smeared out onto the strap making it look messy. •	Whilst the straps apply force, adjustment is limited by the height of the medal and lateral borders. If there is swelling and this swelling subsides, the edges of the device may create a bridging effect over the joints and reduce strap contact. This can be corrected by reducing the height of the medial and lateral trim lines. •	Given the opportunity, a removable liner on the palmer surface, perhaps made of thin lambs wool would be nice to add comfort. This is not essential however.

Overall I think the device meets the prescription design fairly well and given the opportunity, only relatively minor corrections would be necessary to bring the device up to standard.

Outcome measures
In order to monitor progress of night splinting after surgical release of Dupuytren’s contracture in relation to hand function and patient satisfaction, a Disabilities of the Arm, Hand and Shoulder Questionnaire (DASH) could be used. As Jerosch-Herold, Shepstone, Chojnowski, and Larson, D. (2008) state there is no specific outcome tool for Dupuytren’s, however the DASH questionnaire has been validated for use on Dupuytren’s contracture. Range of motion (ROM) of the effected joints could also be used, and even perhaps in conjunction with the DASH questionnaire. ROM as an outcome measure would be preferable in a clinical setting as it would provide fast and reliable monitoring of desired increase of ROM, or reoccurrence of contractures resulting in decreased ROM. The DASH questionnaire would provide more information relating to hand function, pain and patient satisfaction, however the document takes time for the patient to fill out and for the clinician to decipher and extract relevant information. Therefore ROM should be the primary outcome measure used and the DASH questionnaire would be secondary. The DASH questionnaire may be found at http://www.dash.iwh.on.ca/system/files/dash_questionnaire_2010.pdf

References: Jerosch-Herold, C., Shepstone, L., Chojnowski, A. J., & Larson, D. (2008). Splinting after contracture release for Dupuytren's contracture (SCoRD): protocol of a pragmatic, multi-centre, randomized controlled trial. BMC musculoskeletal disorders, 9(1), 62.

Referral
30 May 2014

Ms Jacinta Perm Palpate Physiotherapy Clinic 34 Pleb St	RICHMOND 3121

Dear Jacinta,

Re:	Mr. Barry Burrbutt 30 Dork St RICHMOND 3121 D.O.B: 12/8/1961 Thank you for considering Mr. Burrbutt for your assessment and treatment.

Mr. Burrbutt is 2/52 post fasciectomy to release Dupuytren’s contracture of the right hand involving phalanges 2-5. Full extension at the PIP and DIP joints was surgically achieved however a 45° extension deficit exists in the MCP joints. Wrist ROM is within normal range and his surgical wounds are healing uneventfully, requiring only minor dressing.

Mr. Burrbutt has been wearing a custom low temperature night splint maintaining 45° extension to assist scar remodelling and prevent contracture reoccurrence. He is tolerating the splint well and has reported little discomfort.

Adjustments to the splint will be made in 1/52 time, increasing MCP extension as per surgeon’s instructions. I feel Mr. Burrbutt would benefit greatly from your expertise pre and post this period of adjustment.

With kind regards,

P&O Dept. Big Hospital Richmond

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