**23. Less common wrist related pathologies in a golfing population**

#### **23.1 Dupuytren's contracture**

Dupuytren contracture (**Figure 20b**) is a benign, myeloproliferative progressive disease of the palmar fascia which results in shortening, thickening, and fibrosis of the fascia and aponeurosis of the palm. It results in nodular formation on the palmar fascia which creates fibrosis resulting in one or more fingers become permanently bent in a flexed position. Dupuytrens contracture is caused by progressive

*Leading Wrist Injuries in a Golfing Population. Golf Swing Biomechanics a Significant Cause… DOI: http://dx.doi.org/10.5772/intechopen.96979*

#### **Figure 20.**

*Dupuytren's contracture caused by shortening, thickening, and fibrosis of the fascia and aponeurosis of the palm, results in nodular formation and a flexion deformity at the 4th and 5th digits, making a consistent grip of a golf club difficult.*

thickening and shorting of the palmar fascia. This occurs due to slowly progressing fibrosis in the fascia that results in a flexion deformity at slowly the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints usually affecting the 4th and 5th digits. The disease begins in the palm as painless nodules that form along longitudinal lines of tension. The nodules form cords that produce contracture deformities within fascial bands and tissues of the hand.

The disorder has varying pattern of genetic predisposition across different regions and populations and is also known as the Viking disease, and Celtic hand, with 30% of the over 60-year-old male Norwegian population and 20% of a similar British population suffering from this condition [51].

It is expressed in an autosomal dominant fashion. This *condition* is *most* commonly seen in *populations* of *Northern European*/*Scandinavian descent* [52]**.** It is *relatively uncommon* in *Southern European* and *South American populations*. *Males* are *affected* by a *2:1 ratio compared* to *women*.

The condition is associated with diabetes, seizure disorders, smoking, alcoholism, HIV, and vascular disease Ectopic manifestations beyond the hand can be seen in Ledderhose disease of the plantar fascia Peyronie disease (Dartos fascia of the penis), and Garrod disease (dorsal knuckle pads) [51–53].

Numerous authors going back as far as the 17th century have noted the association between traumatic events and the appearance of Dupuytren's contracture. Initially by Plater in 1614, Goyrand in1835 and, Guillaume. Dupuytren, a French Surgeon in 1833 who the condition is named after [53–56].

Golf has never specifically been cited as a caused of the condition but is a common disability encountered in the older golfer population. The disability causes technical issues gripping and swinging a golf club due to its anatomical location at the base of the wrist and the role of the 4th and 5th digit in gripping a club. Fatigue and hand pain has been reported in elite golfers with this condition and an inability to grip the club consistently.

In a 2017 survey of 504 Dupuytren's sufferers, the Dupuytren's society reported a significant proportion described difficulty golfing due to the pathology. In this

observational study 8% of sufferers without a contracture reported a difficulty, 11% of single hand contracture and 23% of bilateral contracture suffers reported disfunction while golfing [57].

Up to one-fifth of patients seeking treatment for primary Dupuytren's contracture were reported to suffer from an injury-induced Dupuytren's contracture. It was noted that the injury to the wrist and hand seems to trigger the development of less progressive form Dupuytren's contracture in younger age group [58].

In diagnosing Dupuytren Contracture the clinician needs to distinguish the condition from other diseases of the hand including stenosing flexor tenosynovitis, ganglion cysts, ECU tendon subluxation, Guyon's Canal Syndrome and soft tissue masses. Diabetes, seizure disorders, smoking, alcoholism, HIV, and vascular disease should be considered during a careful history due their association with this condition.

Clinically the condition usually progresses at a slow rate over the course of several years and individuals may not be aware of the condition until it starts to cause functional disability. Pits and grooves in the palm of the hand are an early sign followed by the development of nodules in the medial palm. These nodules are often painless. Pain may be present distally at the knuckles pads of the proximal interphalangeal (PIP) as contracture evolve. The disorder is not always progressive and in at least 50–70% of patients, it may stabilise or even regress.

Investigations include radiology, which is usually normal and serology to out-rule metabolic or infective pathologies which are associated such as Diabetes Mellitus, Alcoholism and HIV infection, if there is a clinical suspicion.

Ultrasound [38] is the diagnostic tool with the highest yield as it confirms the presence of thickening of the palmar fascia and nodule formation.

Treatment includes physical therapy during the early stage of the disease. Some patients may also benefit from a brace to stretch the digits and maintaining range of motion of the fingers is necessary to prevent adhesions. This is particularly important in the golfing population. Corticosteroid injections may be beneficial and should be performed using Ultrasound guidance. Needle aponeurotomy is typically reserved for mild contractures. Collagenase injection which is a relatively new, minimally invasive treatment derived from Clostridium histolyticum has shown good initial results. The treatment is not available in all jurisdictions and should only be performed by a hand surgeon who can deal with any potential side effects of this treatment. Surgical fasciectomy is reserved for those cases who have failed conservative therapy and have a persisting disability.

A significant proportion of older golfers suffer from this disability that causes pain, discomfort and impairs the player's ability to consistently grip a golf club, and regularly interferes with the enjoyment of the game. Golf due to trauma may provoke the injury and once present exacerbates the condition. Early identification, finger stretching, as well as the use of topical anti-inflammatory medication assist in reducing symptoms in golfers with mild or non- progressive disease.

Golfers frequently continue to play with this condition. In these instances, the Dupuytren's sufferer should undergo a careful assessment of equipment. Golf shaft weight and grips should be reviewed by a PGA golf professional. In particular, correct or augmented golf grips can facilitate safe and enjoyable golf for the Celtic Hand golfer. Thickening grips can help mitigate overactive hands through the hitting zone thus reducing stress on the palmar aponeurosis. Golf grips come in 4 basic diameters and can be refined by a golf professional by the addition of wraps under the grip, further customising the all-important handle of the golf club. Larger grips also improve shock absorption and reduce transition of force to an already compromised palmar fascia. Small grips result in an increase in grip pressure and a propensity to grip the club in the palm. Holding the club too high across the palm increases the risk of hand injury or the exacerbation of an existing condition. The golfer

*Leading Wrist Injuries in a Golfing Population. Golf Swing Biomechanics a Significant Cause… DOI: http://dx.doi.org/10.5772/intechopen.96979*

should ensure his grip is biomechanically correct and the club is held in the fingers rather than the palm of the hand. This can be achieved by regripping the club in the last three fingers of the leading hand at address, prior to swinging. This helps to stabilises the club at impact and limits the stress on the palm of the hand. These small manageable changes will contribute to lessening the affect that this condition has on recreational and elite golfers.
