The Use of Dynamic Dorsal Splint for Dupuytren Rehabilitation After Collagenase Injection

Fig. 17.1

Volar view after Dupuytren Disease of a digital cord of the fifth finger treated with collagenase of Clostridium histolyticum. A custom-made dorsal dynamic tension-free splint in thermoplastic material applied to the hand

The patients were instructed to change the dressing daily or to massage the volar part in absence of skin lesions with elasticizing cream. Following the therapist’s instructions, they had to free the distal anchorage ring in order to activate the involved finger immediately after the custom-made splint was applied, 20 min 4 times a day for 21 consecutive days (Fig. 17.2). Then they had to wear it only during the night for 5 weeks more. They also learned to self-adjust the tension of the distal ring, to provide progressive soft dynamization of the finger. The patients had to follow two kinesis-assisted sessions a week for the first 3 weeks after injection.

Fig. 17.2

The patient can open the distal anchorage ring to start active and passive finger movement

All the patients received several follow-up visits in the first six months after treatment.

17.3 Results

The results obtained in this trial with collagenase were fully satisfactory and aligned with those reported in literature (Warwick et al. 2015). The use of a dorsal tension-free splint was well tolerated in both MP and PIP cords. Skin problems due to traction were not reported; the patients were instructed on how to calibrate the tension of the distal ring in order to avoid pain, flare reaction (Rivlin et al. 2014), or a complex regional pain syndrome (CRPS).

The patients who had a skin laceration due to post-collagenase manipulation could apply a volar dressing associated to the dorsal splint. They did not report any pain and all had spontaneous skin healing in 17 days on average without stitches or skin graft.

In 26 cases (24 %) revision of the splint shape was necessary for a better adaptation to the tension required. Poor tolerance to dorsal metacarpal compression caused by the splint in the first cases treated resulted in an improved splint design with a thicker padding.

No patients required a premature splint removal for intolerance. There were no cases of allergy to the thermoplastic material used, and the therapists never had to change the dorsal splint for a more commonly used volar device due to intolerance or unsatisfactory traction.

17.4 Discussion

Splinting is a commonly prescribed therapeutic modality designed to maximize the finger extension achieved from DD correction, as a result of open surgery or percutaneous fasciotomy (Kemler et al. 2012). After open aponeurectomy several factors need to be considered for a successful splinting: dressing, perioperative side effects, patient sufficiency, and scar remodeling. The scar evolution continues for up to 6 months after surgery, and splinting aims at providing low-load continuous force in order to prevent contracture recurrence.

Few studies evaluate the real efficacy of postoperative splinting and a meta-analysis of the most recent papers shows that splinting is effective for treatment of DD contracture especially when the PIP joint is involved (Larson and Jerosch-Herold 2008; Jerosch-Herold et al. 2008). Jerosch-Herold et al. demonstrated that patients receiving only hand therapy without splint after surgical approach show a higher tendency to lose finger extension for scar contracture, especially when the surgical scar crosses the MP or the PIP joints (Jerosch-Herold et al. 2008; Jerosch-Herold et al. 2011). The tension applied by the splint to the treated finger has to be low in order to avoid adverse outcomes as flare symptoms and keloid scars (Rivlin et al. 2014).

There is no proven evidence that a dorsal splint is more efficient than a volar one.

In the use of CCH for the treatment of DD, there is a high rate of minor side effects. Twenty-two percent of study patients developed skin lacerations and blood blisters after injection or after manipulation with more severe preinjection deformity showing higher risk. As reported in literature, these side effects are self-solving soft tissue distresses, and, if present, the scar is softer and more easily manageable than the scar left by an open surgery (Hurst et al. 2009). They are well-known conditions, which are not usually considered complications. Less severe pre-intervention contractures tend to correct better, with a lower side effect rate.

After the extension manipulation, the injected skin is softer, the finger is extended, and often cords are no longer palpable in the injection site for a length of 1–3 cm. If a skin wound occurs during manipulation, a simple thin dressing is sufficient in order to help the patient obtain immediate active and passive finger movements. Consequently, a dorsal splint is useful in the treatment of volar skin lacerations without compression to the distressed skin.

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