Dupuytrensche Kontraktur - Folge einer Tätigkeit oder Verletzung?

Gelegentlich wird berichtet, dass eine Dupuytrensche Kontraktur als Folge einer Verletzung oder einer Operation auftritt. Dazu muss vermutlich schon eine Veranlagung für die Dupuytrensche Kontraktur bestehen. Die Verletzung, medizinisch auch Trauma genannt, ist dann der Auslöser für den Ausbruch der Erkrankung. Ein Zusammenhang wird vermutet, wenn die ersten Knoten innerhalb von einigen Wochen oder Monaten nach dem Unfall oder der Operation auftreten. Es können aber auch 1-2 Jahre dazwischen liegen; dann ist der Zusammenhang aber nicht mehr so eindeutig. Die die Operation/Verletzung muss nicht notwendig an der anschließend befallenen Hand erfolgt sein, sie kann auch z. B. am Arm erfolgt sein. Genauso kann der Heilungsprozess auch Knotenbildung an der anderen Hand anstoßen. Ähnliches gilt für die Füße und Ledderhose.

Während die Möglichkeit einer Krankheitsauslösung durch ein Trauma generell in der Medizin anerkannt ist, ist der Nachweis im individuellen Fall schwierig. Trotzdem kann auch nicht ausgeschlossen werden, dass die Dupuytrensche Krankheit in manchen Fällen auch arbeitsbedingt entstanden ist. Dupuytren selbst hat das schon vermutet, in einzelnen Fällen wurde das auch dokumentiert, es gibt aber auch Untersuchungen, die eher das Gegenteil vermuten lassen. Insgesamt ist eine arbeits- oder hobbybedingte Verschlechterung des Krankheitsbildes oder auch eine Entstehung durchaus denkbar, aber wahrscheinlich eher selten. Bei der Handoperation von Dupuytrenpatienten tritt dieser Effekt vermutlich öfter auf, weil die operierten Patienten offensichtlich die entsprechende Veranlagung zur Dupuytrenschen Kontraktur besitzen. Uns sind aber keine entsprechenden Statistiken bekannt.

Im folgenden haben wir Literatur zusammengestellt zur Entstehung einer Dupuytrenschen Kontraktur nach einem Trauma (Handverletzung oder operativer Eingriff). Die meiste Literatur ist leider in Englisch.

Deutsche Literatur:

Walter Gilbeau "Dupuytren'sche Kontraktur und Unfall" Universität Bonn, 1934.

Wilhelm K und Rueff FL "Die Dupuytrensche Faszienfibrose als Verletzungsfolge" Chirurg 6 (1971).

Schröter G "Die Anerkennung der Dupuytrenschen Kontraktur als Berufserkrankung" Beitr Orthop Traumatol. 1971;18(2):78-80

Kirsch A „ Dupuytren sche Kontraktur und Trauma“ Z. Ärztl. Fortbild ( Jena ) 69 (1975) p 325-8.

Brenner P ; Krause-Bergmann A; Van VH „Die Dupuytren-Kontraktur in Norddeutschland. Epidemiologische Erfassungsstudie anhand von 500 Fällen.“ Der Unfallchirurg 104 (2001) p 303-11. Zusammenfassung

"Signifikant unterschieden sich die Tubiana-Werte für Intellektuelle gegenüber Schwerarbeitern. ... Schwerarbeiter leiden an einem fortgeschritteneren Dupuytren-Grad. ... Trotz Traumaanamnese zählt der Morbus Dupuytren weiterhin nicht als Berufserkrankung."

Peter Brenner und Ghazi M. Rayan "Morbus Dupuytren - Ein chirurgisches Therapiekonzept" (Springer, Wien, 2002). Speziell zum Zusammenhang zwischen Trauma und Dupuytrenscher Kontraktur siehe Kapitel 4.1.

Wichelhaus, A.; Wendt, M.; Mielsch, N.; Gradl, G.; Mittlmeier, T. "Dupuytrenknotenbildung nach Operation einer distalen Radiusfraktur" Handchir Mikrochir plast Chir 2015; 47(01): 38-43 Zusammenfassung

Schlussfolgerung: "Das Auftreten von Dupuytrenknoten kann durch ein Trauma und/oder eine Operation getriggert werden, wobei es sich möglicherweise um eine eigene Erkrankungsentität des Morbus Dupuytren handelt, konnte doch keine Progredienz der Veränderungen im Beobachtungszeitraum beobachtet werden."

Englische Literatur:

Moorhead JJ “Trauma and Dupuytren's contracture” Am J Surg 85 (1953) 352-8. – Kein Abstract verfügbar.

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 is studied in 901 persons 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. Persons with Dupuytren's disease have sustained previous hand trauma more frequently than the general population, and the interval between trauma and 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. The study has indicated that Dupuytren's disease in certain cases is precipitated and/or aggravated by both work and definite hand injury.

 

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.

Hueston JT, Seyfer AE "Some medicolegal aspects of Dupuytren's contracture" Hand Clin. 1991 Nov;7(4):617-32

This article presents the medical and legal aspects of Dupuytren's contracture. It also presents a rational basis for the assessment of the relationship, if any, between a patient's occupation and the development of Dupuytren's contracture.

Liss GM; Stock SR „ Can Dupuytren's contracture be work-related?: review of the evidence” American journal of industrial medicine 29 (1996) 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 methodologic 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 local 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.

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.”

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."

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."

Lucas G, Brichet A, Roquelaure Y, Leclerc A, Descatha A. "Dupuytren's disease: Personal factors and occupational exposure" Am J Ind Med. 51 (2008) p 9-15 Link

"CONCLUSION: Manual work exposure was associated with Dupuytren's disease after adjustment for personal risk factors. Longitudinal studies are needed to confirm these results."

 

Der folgende Artikel beschreibt einen möglichen Mechanismus für das Anschieben der Dupuytrenschen Krankheit durch eine OP bzw. ein Trauma:

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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