# Upper Limb Orthotics/Dupuytren's disease
## Describe your case study

The client is a 54 year old male basketball coach, of Scottish descent, who works at the local high school. He is fit and healthy in all aspects but has been suffering from the impact of Dupuytren's contractures for (approximately) the previous two (2) years. Dupuytren's is present in both hands, with the metacarpalphalangeal and proximal interphalangeal joints of the fourth and fifth digits on both hands being affected. The contracture's had not previously been to such a degree that they were overly impacting on the client's day to day activities, up until (approximately) 3 months ago, when he felt they were having a negative impact on his ability to coach basketball properly, and various other daily activities. The client expressed frustration about not being able to dribble or catch the ball properly, his driving was becoming increasingly difficult, and even the simple ability to put gloves on to keep himself warm was no longer possible. Upon measuring the angle of contracture at the MCP joints with a goniometer, it was found that his Dupuytren's had progressed to such a degree that surgery was warranted (Goniometer measurements were greater than the 30 degrees recommended for surgery). Upon successful completion of the surgery on both hands, it was suggested that orthotic management with a resting splint to maximise extension of the affected digits, would be beneficial to the client and aid him in returning to full functionality.

## Written information
### Dupuytren's Disease

Dupuytren’s disease or Dupuytren’s contracture is a progressive disease of the upper limb that affects the volar surface of the hands (Bayat & McGrouther, 2006; Warwick, Thomas & Bayat, 2012). It is a benign, generally painless, contractile condition of the palmar fascia that (Warwick et al., 2012; Worrell, 2012) results in permanent flexion deformity of the fingers (Bayat & McGrouther, 2006; Riolo, Young, Ueda & Pidgeon, 1991). There is no known cure for the disease and therefore much conjecture over the best form of management. The aetiology of Dupuytren’s disease is unkown (Evans, Dell & Fiolkowski, 2002), although it is apparent there is a genetic linkage (Bayat & McGrouther, 2006; Riolo et al., 1991; Swartz & Lalonde, 2008; Warwick et al., 2012), with a prevalence in white males of either a Celtic or Germanic ancestry (Bayat & McGrouther, 2006; Riolo et al., 1991; Swartz & Lalonde, 2008; Uzor, Maldjian, & Adam, 2011; Warwick et al., 2012; Worrell, 2012). Age is also a determinant factor, with there being a higher prevalence in individuals after the age of fifty (Riolo et al., 1991; Swartz & Lalonde, 2008; Uzor et al., 2011; Warwick et al., 2012; Worrell, 2012). There are associated risks connected with Dupuytren’s contractures to diseases such as epilepsy, diabetes, alcoholism and smoking (Riolo, et al., 1991; Uzor et al., 2011; Warwick et al., 2012) although the exact connection is still not completely understood.

### Pathophysiology

Various studies indicate that the pathophysiology involved in Dupuytren’s disease is a similar process that occurs with normal wound healing (Bayat & McGrouther, 2006; Warwick et al., 2012), - an increased proliferation of fibroblasts; which then differentiate into myofibroblasts; causing collagen deposition which results in the contractural cord like structures (Bayat & McGrouther, 2006; Riolo et al., 1991; Warwick et al., 2012).

### Clinical Presentation

The clinical presentation of Dupuytren’s disease starts with the appearance of nodules on the palm, which is a result of the palmer fascia thickening (Bayat & McGrouther, 2006; Swartz & Lalonde, 2008;), usually at the base of either the small, or ring finger (Riolo et al., 1991). Further thickening of the palmer fascia leads to formation of palpable cord like structures, which extend into the affected fingers from the palm (Bayat & McGrouther, 2006; Riolo et al., 1991; Swartz & Lalonde, 2008), and can cause contractures of the metacarpophalangeal joints and/or the proximal interphalangeal joints (Riolo et al., 1991; Swartz & Lalonde, 2008; Uzor et al., 2011; Warwick et al., 2012), with the fingers most commonly affected being the fourth (ring finger) and fifth (little finger) digits (Bayat & McGrouther, 2006; Swartz & Lalonde, 2008; Worrell, 2012). Dupuytren’s disease can affect either or both hands, with over 50% of people presenting with a bilateral condition, (Bayat & McGrouther, 2006; Riolo et al., 1991) and contractures can progress until the fingertips will ultimately touch the palm (Riolo et al., 1991). As is the case with this patient, most people with Dupuytren’s disease generally do not seek assistance until the contracture begins to impact on their daily lives, making simple tasks like washing their face, combing their hair or driving, harder to perform (Ball, Pratt & Nanchahal, 2013; Bayat & McGrouther, 2006; Swartz & Lalonde, 2008).

### Testing & Measuring

Simple tests and measures that can be performed to indicate the presence of Dupuytren’s disease vary between clinicians but can include the Hueston Table Top Test (Bayat & McGrouther, 2006; Hueston, 1976 as cited in Brenner, 2002; Swartz & Lalonde, 2008; Warwick et al., 2012;), whereby a patient endeavors to place their palm flat on a table, and if unable to do so the test is positive. Range of motion measurements using a goniometer to measure the affected joint angles, is also an effective means to note the disease progression (Brenner, 2002; Warwick et al., 2012), which can lead to further classification by Tubiana (Tubiana, 1986 as cited in Warwick et al., 2012) of the four categories of deformity – Stage I: 0-45°; Stage II: 45-90°; Stage III: 90-135° and Stage IV: 135-180° (Tubiana, 1986 as cited in Warwick et al., 2012).

### Treatment Options

There is no known cure for Dupuytren’s disease but it can be managed, to varying degrees of success, with a variety of clinical alternatives (Bayat & McGrouther, 2006; Larocerie-Salgado & Davidson, 2011; Riolo et al., 1991; Swartz & Lalonde, 2008; Warwick et al., 2012), the most basic of which is to simply observe and monitor the condition of the hand, if only nodules are present and functionally impairing contractures are not yet apparent (Swartz & Lalonde, 2008; Warwick et al., 2012). According to Larocerie-Salgado and Davidson (2011), the use of night time extension splints in conjunction with stretching and massage of the contracted tissue, can delay disease progression and improve mobility for individuals in the early stages of Dupuytren’s disease, though most other reviewed literature indicates that orthotic management only comes into play postoperatively (Bayat & McGrouther, 2006; Clare, Hazari & Belcher, 2004; Swartz & Lalonde, 2008; Worrell, 2012). Other clinical management options, which are gaining wider understanding and acceptance, include radiotherapy - which is thought to be only effective in early stages of the disease before contracture occurs; steroid injection – again only thought to be effective in early disease stages; and injectable collagenase – which directly dissolves the abnormal collagen within the thick cord like structures (Warwick et al., 2012). All of these options require further testing to provide any conclusive basis for evidential practice.
The gold standard for management of Dupuytren’s disease is that of surgery, (Bayat & McGrouther, 2006; Swartz & Lalonde, 2008) with metacarpophalangeal contractures of 30° and above being generally indicative that surgery would be of benefit (Riolo et al., 1991; Swartz & Lalonde, 2008). Surgery tends to gain functional improvement for the patient, which includes achieving not only extension of the affected digits, but also maintaining some degree of flexion so that the hand is a useful and functioning part of the body (Bayat & McGrouther, 2006). Surgical options include divisions of the affected fascial cord (fasciotomy), excisions of the diseased fascial cord (partial or total fasciectomy), or excision of both the diseased fascial cord as well as the overlying skin (dermofasciectomy) (Bayat & McGrouther, 2006; Jerosch-Herold et al., 2011; Swartz & Lalonde, 2008; Warwick et al., 2012). Although there is a great degree of success with any of the operative measures for releasing Dupuytren’s contracture (Bayat & McGrouther, 2006; Swartz & Lalonde, 2008; Warwick et al., 2012), recurrence of the disease is relatively high (Bayat & McGrouther, 2006; Swartz & Lalonde, 2008), which can ultimately lead to amputations (Swartz & Lalonde, 2008).

### Orthotic Management

According to the literature it is postoperatively, that orthoses are used in the management of Dupuytren’s disease (Bayat & McGrouther, 2006; Clare et al., 2004; Swartz & Lalonde, 2008; Worrell, 2012). The use of thermoplastic extension splints at night and/or daytime, as well as regular therapy sessions with a hand therapist/physiotherapist, may aid in the recovery process postoperatively (Bayat & McGrouther, 2006; Jerosch-Herold et al., 2011), although there is much conjecture within the reviewed literature as to whether there is any greater benefit to splinting than purely hand therapy alone (Jerosch-Herold et al., 2011; Kemler, Houpt & van der Horst, 2012; Larson & Jerosch-Herold, 2008; Warwick et al., 2012). Within the literature there is no general consensus on the type of orthoses to be used nor the duration of use (Kemler et al., 2012; Larson & Jerosch-Herold, 2008), though it would seem apparent that an orthosis designed to maximise extension of both the metacarpophalangeal and proximal interphalangeal joints would be appropriate (Clare et al., 2004; Jerosch-Herold et al., 2011).

### Comparison of Orthotic vs Surgical Management

In comparing the orthotic and surgical management, there is still much conjecture over the best means to achieve the greatest functional outcome for those presenting with Dupuytren’s contracture, or whether indeed orthotic intervention has any place within the management protocol. Currently surgery is the standard when it comes to providing management, though much research is still needed to come to any conclusive decisions about orthotic management of Dupuytren’s disease.