Dupuytren's contracture and trauma. Can Dupuytren's contracture be work or occupation related?
The possible connection between an injury of the hand (a trauma in medical terms) and the onset of Dupuytren's contracture has frequently been discussed. It has been reported in a number of cases but is difficult to prove cause and effect for the individual patient. Dupuytren himself suspected work-related damage to the hand as a reason for this disease (coachman's hand), but obviously also people can develop Dupuytren's contracture without being ever exposed to heavy manual work. See also G Rayan "Dupuytren’s Disease vs Non-Dupuytren’s Contracture" JHS 30A (2005) 1019-20 full_text.
More recently, an increasing number of cases has been reported where damage to the hand, due to an accident, work, or even surgery, has triggered Dupuytren's contracture. There is also indication that trauma elsewhere can trigger or foster Dupuytren's disease.
Studies including private occupation exhibit manual stress as a risk more clearly. Obviously onset of Dupuytren's does not happen to each and every patient - it needs a (probably inherited) disposition to acquire this disease. However, it is possible that a not yet noticed, still "dormant"and maybe not yet palpable nodule starts growing after the hand had been injured. The healing process may be the driving force in those cases, and this might also explain why some patients develop Dupuytren's even after an accident/surgery elsewhere, e.g. an injury of the arm rather than the hand.
Another mechanism that might induce Dupuytren's contracture is repeated minimal damage. In this case the patient experiences no single dramatic injury, but is exposed to a regular, repetitive micro-damage of the hand. There is some indication that Dupuytren's contracture might be a chronic inflammatory disease. Manual work with high cumulative exposure in terms of force and/or vibrations transmitted to the upper limbs could also cause or significantly aggravate Dupuytren’s disease.
Below is a collection of literature that deals with trauma and its relationship to Dupuytren's contracture. The articles are sorted by publication date.
Moorhead JJ “Trauma and Dupuytren 's contracture” Am J Surg 85 (1953) 352-8. – No abstract available.
Zachariae L "Dupuytren's contracture. The aetiological role of trauma" Scand J Plast Reconstr Surg 5 (1971) 116-119. "860 patients with Dupuytren's contracture were questioned concerning factors which might elucidate the possibility that the contracture was aetiologically conditioned by trauma or by manual work. ... From the data it may be concluded that trauma is of no importance in the aetiology of Dupuytren's contracture."
Mikkelsen OA “ Dupuytren 's disease--the influence of occupation and previous hand injuries” Hand 10 (1978) p 1-8
The influence of handedness, work and previous hand trauma was studied in 901 people with Dupuytren 's disease, collected in an epidemiological study of 15,950 citizens in a small, Norwegian town. Dupuytren 's disease occurred in all occupational groups, but the prevalence was higher and the contracture more severe in people doing hard manual work than in people doing light or non-manual work. People with Dupuytren 's disease sustained previous hand trauma more frequently than the general population, and the interval between the trauma and the first sign of disease was usually a few years. Previous hand injuries were definitely more common among people doing hard manual work, but even when these were excluded from the work material, Dupuytren 's disease was still more common among people doing hard manual work, than in people doing light or non-manual work. This study indicates that Dupuytren 's disease in certain cases is precipitated and/or aggravated by both manual work and a definite hand injury.
B. Bennett "Dupuytren's contracture in manual workers" Br J Ind Med. 39 (1982) p 98–100.
de la Caffinière JY, Wagner R, Etscheid J, and Metzger F. "Manual labor and Dupuytren disease. The results of a computerized survey in the field of iron metallurgy" Ann Chir Main. 2 (1983)p 66-72. abstract
" ... a careful study of their working conditions showed a definite correlation between hard manual work over many years and the occurrence of Dupuytren's disease, especially in the younger age group. ... Although Dupuytren's disease cannot be considered as an occupational disease, its development, is favored by hard manual work for at least 10 years. The initiating role of trauma, especially a fracture of the wrist, is confirmed."
McFarlane RM, Shum DT. A single injury to the hand. In: McFarlane RM, McGrouther DA, Flint MH, eds. “ Dupuytren 's disease: biology and treatment” ( New York 1990): p 265-273.
“… we have shown that occasionally a single injury can precipitate the onset of DD”
McFarlane RM “ Dupuytren 's disease: relation to work and injury” J Hand Surg (Am) 16 (1991) 775-9
The present status of adjudication for workers claiming compensation for Dupuytren 's disease is inconsistent and, therefore, unfair to both workers and employers. In some Eastern European countries Dupuytren 's disease is classified as an industrial disease , whereas in other countries it is considered to have no relation to manual work or hand injury. In jurisdictions that sometimes award compensation, the reasons for acceptance or rejection of a claim vary from case to case and are not necessarily based on our present knowledge of the disease. The purpose of this communication is to highlight the features of Dupuytren 's disease that are pertinent to manual work and hand injury and to suggest guidelines that would provide some consistency in the adjudication process. It is hoped that these guidelines would be valuable to the individual surgeon, insurance agencies, and compensation boards.
Thomas PR and Clarke D. " Vibration white finger and Dupuytren's contracture: are they related?" Occup Med (Lond). 42 (1992) p 155-8.
Vibration white finger (VWF) is an industrial injury, also called Hand-Arm Vibration Syndrome or HAVS. "311 were aged 50-85 years, and of these 62 (19.9 per cent) had Dupuytren's contracture. Statistically, this prevalence was significantly higher than that in a control group of 150 men of similar age distribution (10.7 per cent). As far as can be ascertained, this is the first study to indicate that there may be a causal relationship between VWF and Dupuytren's contracture, and the possible theoretical reasons for this are discussed."
Occupational Disease Panel, Toronto, Canada "Report to the Workers' Compensation Board on Dupuytren's Contracture and Hand Injury" ODP Report no. 17, September 1996. Full text
"The Panel finds the evidence of an association between manual work and Dupuytren's Contracture inconclusive and a probable connection has not yet been established. ... The Panel finds a probable connection between Dupuytren's Contracture and vibration exposure. ... All of this evidence leads the Panel to conclude that a probable connection exists between the onset of DC in a hand following an injury." (Cf. below paper by Liss and Stock).
Lanzettá M; Morrison WA „ Dupuytren 's disease occurring after a surgical injury to the hand” Journal of hand surgery (Br) 21 (1996) p 481-3
We report three clinical cases in which Dupuytren 's disease was triggered by surgical trauma. All patients developed the contracture between 3 weeks and 3 months after operation for unrelated pathology of the hand. They had significant swelling of the hand postoperatively, preventing full mobilization. They did not have a strong diathesis for the disease. Since the appearance of the contracture, they have not developed the disease in the contralateral hand or anywhere else in the body. In one case, a similar operation on the contralateral band has not provoked onset of the disease.
Moermans JP “Place of Segmental Aponeurectomy in the Treatment of Dupuytren 's disease ” PhD Thesis (1997) Université Libre de Bruxelles. See e.g. http://www.ccmbel.org/These.html#intro
Specifically on trauma: chapter 9.8.1 Local trauma. – “ The relation found with the involvement of both hands and the age of onset could then be interpreted as the fact that the local trauma acts as a trigger mechanism in predisposed patients. ”
Liss GM; Stock SR „ Can Dupuytren 's contracture be work-related?: review of the evidence” American journal of industrial medicine 29 (1998) p 521-32
Dupuytren 's contracture (DC) is a disease of the palmar fascia resulting in thickening and contracture of fibrous bands on the palmar surface of the hands and fingers. For decades, a controversy has existed regarding whether acute traumatic injury or cumulative biomechanical work exposure can contribute to the development of this disorder. To address this controversy, this review considers the following questions: Is there evidence that DC is associated with 1) frequent or repetitive manual work; and 2) hand vibration? The published literature was searched for studies meeting the following criteria: 1) in English or having an English abstract; 2) controlled studies; 3) DC an identified health outcome studied; and 4) the study group exposed to repetitive or frequent manual work, vibration, or acute traumatic injury. … Of these, four studies met the criteria for methodological quality, one addressing the relationship between manual work and DC, and three studies of vibration and DC. No controlled studies of acute trauma and DC were identified. Bennett [1982: Br J Ind Med 39:98-100] found the prevalence of DC at a British PVC bagging and packing plant in which workers were exposed to repetitive manual work to be 5.5 times that at a lo cal plant without packing, and twice the expected prevalence in a U.K. working population previously studied by Early [1962: J Bone Joint Surg 44B:602-613]. DC was observed more frequently among vibration white finger claimants than controls by Thomas and Clarke [1992: J Soc Occup Med 42:155-158] (OR, 2.1; 95% CI, 1.1-3-9), and more frequently among vibration-exposed workers than controls by Bovenzi et al. [1994: Occup Environ Med 51:603-611] (OR, 2.6 95% CI, 1.2-5.5). Cocco et al [1987: Med Lav 78:386-392] found that a history of vibration exposure occurred more frequently among cases of DC than among controls (OR, 2.3; 95% CI, 1.5-4.4). The latter two studies presented some evidence of a dose-response relationship. There is good support for an association between vibration exposure and DC.
Connelly TJ „Development of Peyronie's and Dupuytren 's diseases in an individual after single episodes of trauma: a case report and review of the literature” Journal of the American Academy of Dermatology 41 (1999) 106-08
A case is presented in which a patient experienced the development of both Dupuytren 's disease and Peyronie's disease after single episodes of sports-related trauma. These disorders and other fibromatoses are linked not only by similar pathologic features but by increased frequency of simultaneous occurrence. Some genetically predisposed individuals experience the development of the disorders after trauma or after some other factor unmasks that predisposition. A review of the literature with emphasis on the relationship between these fibromatoses and the varied nonsurgical attempts at treatment is presented.
Khan AA, Rider OJ, Jayadev CU, Heras-Palou C, Giele H, Goldacre M. "The role of manual occupation in the aetiology of Dupuytren's disease in men in England and Wales" J Hand Surg [Br]. 2004 Feb;29(1):12-4 Link
"We found that manual occupational social class was not associated with an increased incidence of Dupuytren's disease. In fact, the incidence rates of Dupuytren's disease in the elderly were higher in non-manual than in manual social classes."
"Dupuytren's disease / Author's reply" J. Bone and Joint Surgery, Sep 2004. A comment from CP Burge questions whether Dupuytren's disease is work related and Alan J. Thurston responds to it.
Elliot D, Ragoowansi R “ Dupuytren 's disease secondary to acute injury, infection or operation distal to the elbow in the ipsilateral upper limb--a historical review.” J Hand Surg [Br] 30 (2005) p 148-56.
The aggregated total of 385 cases of Dupuytren 's disease arising after acute or specific injury, operation or infection of the forearm, wrist or hand between 1614 and 2003 are documented, including a personal series of 52 cases. The history of this relationship is recorded and the medico legal implications of the association are discussed.
Logan AJ, Mason G, Dias J, Makwana N. "Can rock climbing lead to Dupuytren’s disease?" Br J Sports Med 39 (2005) p 639–644. Link_full_text_PDF
"This study further strengthens the hypothesis that repetitive trauma to the palmar fascia predisposes to the development of Dupuytren’s disease in men."
Abe Y, Rokkaku T, Ebata T, Tokunaga S, Yamada T. "Dupuytren's disease following acute injury in Japanese patients: Dupuytren's disease or not?" J Hand Surg Eur 32 (2007) p 569-72.
"This paper reports the development of Dupuytren's disease following acute injury in 16 hands in 14 Japanese patients. ... Our results suggest that Dupuytren's disease following acute injury could be considered a separate entity from typical Dupuytren's disease. At present, we believe that this condition should be considered a subtype of Dupuytren's disease."
"CONCLUSION: Manual work exposure was associated with Dupuytren's disease after adjustment for personal risk factors. Longitudinal studies are needed to confirm these results."
Alexis Descatha, Pénélope Jauffret, Jean-François Chastang, Yves Roquelaure and Annette Leclerc "Should we consider Dupuytren’s contracture as work-related? A review and meta-analysis of an old debate"BMC Musculoskeletal Disorders 2011, 12:96 Full_text "These results support the hypothesis of an association between high levels of work exposure (manual work and vibration exposure) and Dupuytren’s contracture in certain cases."
Not an article but a recent book:
Peter Brenner and Ghazi M. Rayan "Morbus Dupuytren - a concept of surgical treatment" (Springer, New York , 2003). Specifically the context between trauma and Dupuytren ’s contracture, see chapter 4.1.. Rayan proposes elsewhere that people acquiring contracture after a trauma don't really have Dupuytren's contracture but something else. We haven't seen any follow-up on his proposal.
An article assessing a potential mechanism:
Bisson MA, McGrouther DA, Mudera V, Grobbelaar AO. " The different characteristics of Dupuytren's disease fibroblasts derived from either nodule or cord: expression of alpha-smooth muscle actin and the response to stimulation by TGF-beta1" J Hand Surg [Br] 28 (2003) p 351-6.
"TGF-beta(1) stimulation causes an increased myofibroblast phenotype to similar levels in both nodule and cord, suggesting that previously quiescent cord fibroblasts can be reactivated to become myofibroblasts by TGF-beta(1). This could be an underlying reason for high recurrence rates seen after surgery or progression following injury."
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