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Volar Extension Orthosis (Dupuytren's)

Information

Description of Intervention

Dupuytren’s disease is a chronic, fibroproliferative disorder that can affect many areas of the body. When it produces fibrosis of the palmar and/or digital fascia, it is called Dupuytren’s contracture. The application of a splint, usually a volar extension splint, may be used in the treatment of Dupuytren’s contracture after a collagenase Clostridium histolyticum (CCH) injection or surgical procedure. 1-4

Conservative treatment may be indicated initially for mild cases of Dupuytren’s contracture with minimal to no contracture. Nonsurgical options that have been investigated include physical therapy, therapeutic ultrasound, steroid injections, and vitamin E supplementation, but most of these interventions have not been deemed clinically useful. The most common and effective conservative treatment option is injectable CCH, which weakens fibrous cords and allows them to be more easily ruptured by manipulation. The most popular surgical intervention for Dupuytren’s contracture is limited or partial fasciectomy, which is an open procedure that removes all affected fascia in the palm and digit. Other surgical options include fasciotomy, dermofasciectomy, and percutaneous needle aponeurotomy.

Volar extension splints are typically prescribed after CCH injections and surgery to optimize outcomes. Splinting provides a low-load continuous force to the hand and fingers, which maintains the correction achieved through surgery and prevents contracture recurrence. Splints are normally worn at night—although some are also worn during the day—for about 3 to 6 months, since scar maturation continues for this duration. Although splinting is generally recognized to have a role following surgery, not all surgeons use it, and when utilized, splinting is combined with other techniques and modalities intended to promote wound healing, manage scar tissue, maximize finger extension and flexion, and restore function.

Indications for Intervention

A volar extension splint is indicated for patients with Dupuytren’s contracture who undergo surgery or a CCH injection to maintain the correction achieved through surgery. In rare cases, it may also be used as an independent conservative intervention.

  1. Ask the patient to describe their medical history, including if any family members have been diagnosed with Dupuytren’s contracture.
  2. Ask if the patient has any comorbidities, including diabetes, osteopenia, cardiovascular issues, or a history of smoking.
  3. Perform a physical examination of the hand and wrist. Look for signs of Dupuytren’s contracture, such as palpable lumps and pits on the surface of the hand. If any nodules or cords are identified, record the location of each.
  4. Assess the active and passive range of motion (ROM) of the fingers and thumbs of both hands.
  5. Ask the patient to rate their pain on the visual analogue scale (VAS) or a similar pain scale.
  6. If Dupuytren’s contracture is present, perform a tabletop test to assess the extent of the condition.

Orthoses Guidelines2,5-9

If the patient is a good candidate for a volar extension splint for Dupuytren’s contracture, provide the patient with a splint within the first 10 days after surgery or CCH injection. You may select either a prefabricated, custom-fitted, or custom-fabricated splint: 

  • Prefabricated splint: these splints are made by a manufacturer and can be purchased over the counter at pharmacies or with a prescription from orthopedic supply stores; therefore, prefabricated splints are not individualized for the patient and do not require any special fitting services, but patients can make minimal adjustments with Velcro straps to ensure the splint fits properly
  • Custom-fitted splint: this is a type of prefabricated splint that requires bending, cutting, or molding the splint to fit the patient’s hand properly; it may be necessary to apply heat to manipulate the splint
  • Custom-fabricated splint: these splints are individualized for each patient by taking castings, measurements, tracings, and images of the injured area that are used to create a specialized splint; you will then fabricate the splint by molding, drilling, sewing, or bending the splint material before fitting and applying it to the patient

Custom-fitted and custom-fabricated splints are strongly recommended for most patients, but a prefabricated splint may be sufficient in some cases. Volar extension splints can be constructed with a variety of materials, including plaster, fiberglass, padding, ace wraps, metal, cloth, plastic, or leather. If fitting or fabricating the splint, ensure that it fits comfortably. Pain medications may be needed before and during the splinting process. The splint should also allow for maximal sensory perception, and the pressure of the splint should be distributed equally. It should not challenge the normal contours of the hand and forearm. A small splint is often sufficient for one or two fingers, but a splint covering more than two-thirds of the lower arm may be needed when more fingers are involved or when full active extension is not achieved during surgery. The splint should keep the wrist and metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in 0° of flexion.

After the splint is applied, provide the patient with wear and care instructions, including cleaning directions, which vary by splint. Instruct the patient to either wear the splint only at night or also during the day. Some therapists recommend wearing the splint 24 hours a day for the first 4 weeks, then switching to nights only afterwards. After outfitting the splint, assess the patient’s hands periodically and adjust or remold the splint to accommodate any noted improvements. The total duration the splint should be worn for depends on the severity of the contracture, the intervention performed, and provider preference, but 3–6 months is often required to allow for scar maturation and reduce the risk for contracture recurrence.

A volar extension splint is typically supplemented with a hand therapy program, which should include exercises designed to improve the strength, mobility, and function of the affected hand.  The addition of dynamic splints may be used when trying to correct joint contractures, scar contraction, and long flexor tightness.  They can be worn for 20-40 minute intervals, 2-5 x per day.

Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Although splinting is frequently prescribed, the exact mechanism of action behind its beneficial effects not yet been established. One theory suggests that the application of axial tension to the cord increases the activity of matrix metalloproteinases, which then interferes with the balance between collagen resorption and deposition.2
  • Evidence on the effectiveness of nightly volar extension splinting following needle aponeurotomy is limited, and some research has suggested that it may not be necessary in these cases.10
  • One study found that static night splinting was effective as a standalone intervention in the early stages of Dupuytren’s disease. The authors suggested that splinting may also serve a role in treating established disease and for patients who are unfit or unwilling to undergo surgery.2
  • The postoperative management of Dupuytren’s contracture varies widely between healthcare providers, and research has not clarified the optimal approach.9
References
  1. Hovius SER, Zhou C. Advances in Minimally Invasive Treatment of Dupuytren Disease. Hand Clin2018;34(3):417-426. PMID: 30012301
  2. Ball C. The Use of Splinting as a Non-Surgical Treatment for Dupuytren’s Disease: A Pilot Study. British Journal of Hand Therapy 2002;7(3):73–75.
  3. Chojnowski A, Wach W, Degreef I. Controversy: Splinting for Dupuytren Contracture. In: Werker PMN, ed. Dupuytren Disease and Related Diseases – The Cutting Edge. Switzerland: Elsevier; 2017.
  4. Larson D, Jerosch-Herold C. Clinical effectiveness of post-operative splinting after surgical release of Dupuytren's contracture: a systematic review. BMC Musculoskelet Disord 2008;9:104. PMID: 18644117
  5. Alam J, Ponnarasu S, Varacallo M. Thumb Spica Splinting. In: StatPearls. Treasure Island (FL) 2022.PMID: 30860760
  6. Awan WA, Babur MN, Masood T. Effectiveness of therapeutic ultrasound with or without thumb spica splint in the management of De Quervain's disease. J Back Musculoskelet Rehabil 2017;30(4):691-697. PMID: 28035912
  7. Rocchi L, Merolli A, Morini A, Monteleone G, Foti C. A modified spica-splint in postoperative early-motion management of skier's thumb lesion: a randomized clinical trial. Eur J Phys Rehabil Med 2014;50(1):49-57. PMID: 24185690
  8. Kitridis D, Karamitsou P, Giannaros I, Papadakis N, Sinopidis C, et al. Dupuytren's disease: limited fasciectomy, night splinting, and hand exercises-long-term results. Eur J Orthop Surg Traumatol 2019;29(2):349-355. PMID: 30413875
  9. Kemler MA, Houpt P, van der Horst CM. A pilot study assessing the effectiveness of postoperative splinting after limited fasciectomy for Dupuytren's disease. J Hand Surg Eur Vol 2012;37(8):733-737. PMID: 22311918
  10. Tam L, Chung YY. Needle aponeurotomy for Dupuytren contracture: Effectiveness of postoperative night extension splinting. Plast Surg (Oakv) 2016;24(1):23-26. PMID: 27054134
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