Dupuytren’s Contracture

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Dupuytren’s Contracture

Dupuytren’s disease is a condition that affects the fascia—the fibrous layer of tissue that lies underneath the skin in the palm and fingers. In patients with Dupuytren’s, the fascia thickens, then tightens over time. This causes the fingers to be pulled inward towards the palm, resulting in what is known as a “Dupuytren’s contracture.”

 In some patients, a worsening Dupuytren’s contracture can interfere with hand function, making it difficult to perform their daily activities. When this occurs, there are non-surgical and surgical treatment options available to help slow the progression of the disease and improve motion in the affected fingers.

What is Dupuytren’s contracture?

Dupuytren’s contracture, or Dupuytren’s disease, is a hand deformity that consists of the thickening of tissues located under the palm and results in one or more of the fingers become permanently bent in a flexed position.
 
 
When the syndrome starts, knots or lumps form in the palm that prevents the fingers from straightening. Daily activities, such as handshaking or putting your hand in your pocket, can be complicated.
 
This condition typically affects the ring finger and the little finger and worsens slowly over many months or years. It is more prevalent in older men originating in Northern Europe.
 

Other names
Viking’s disease

Who does it affect?
Usually males over the age of 40 years, occasionally females.

What is Dupuytren’s, and why does it occur?

The fascia is a layer of tissue that helps anchor and stabilize the skin on the palm side of the hand. Without the fascia, the skin on your palm would be as loose and moveable as the skin on the back of your hand. In patients with Dupuytren’s disease, this palmar fascia slowly begins to thicken, then tighten.

Often, Dupuytren’s is first detected when lumps of tissue or nodules form under the skin in the palm. This may be followed by pitting on the surface of the palm as the diseased tissue pulls on the overlying skin.

Dupuytren’s disease is a thickening of the palmar fascia in the hand and fingers. I refer to it in lay terms as a type of canvas that sticks the skin to the deeper structures, giving firmness to the palm and fingers, allowing a good grip. This is in contrast to the back of the hand, where the skin is mobile and would not provide such rigidity to pick objects if on the palm.
In the palmar fascia, there are cells called myofibroblasts. In Dupuytren’s disease, these cells multiply, proliferate and eventually contract. They form nodules and cords like structures in the palm and finger that gradually pull the fingers over into the palm.

There are several risk factors associated with developing Dupuytren’s disease. These include, amongst others: genetic (inherited), diabetes, excess alcohol intake, epilepsy and/or its treatment. In most patients, we do not know why they develop the disease, but it is probably inherited to some extent. 

Symptoms
Thickening and cord-like structures develop gradually in the palm and extend into the fingers, causing the fingers to roll up into the palm. An advanced case is shown in the photograph at the top of the page. In the initial stages, the nodules can be tender, but the pain usually settles. 

Symptoms can arise such as :
• An inability to place the hand flat on a table, 
• Catching your eye with a finger when washing your face, 
• Inability to get a hand in pocket, 
• And problems shaking hands.

Clinical Examination
The disease is usually straightforward to diagnose and has a very characteristic appearance. Nodules and cord-like structures develop in the palm and may extend down onto the front of the finger. As the disease progresses, the fingers may curl over into the palm.

A simple test to try and evaluate the severity of the disease is the “tabletop test”. The patient is asked to place the hand flat on the table. If they are unable to do so, it is likely that the disease may need surgery in the future.

What is the cause of Dupuytren’s contracture?

The cause of Dupuytren’s contracture is unknown, but it could be associated with certain biochemical factors within the affected tissue. Knowing the risk factors can allow early detection and treatment.

Factors that increase the risk of developing this condition include:
Age – occurs more frequently after the age of 40
Sex – men are more likely to develop Dupuytren’s contracture than women
Genetics – People of Northern European descent are at increased risk of developing the condition
Family history – Dupuytren’s contracture is often hereditary.
Tobacco and alcohol use – Smoking is associated with an increased risk of Dupuytren’s contracture, perhaps due to microscopic changes in smoking caused by blood vessels. Alcohol consumption is also associated with Dupuytren’s contracture.
⦁ Diabetes – People with diabetes have been reported to be at increased risk of developing Dupuytren’s contracture

Medical tests for Dupuytren’s contracture
Most of the time, a specialist will perform a physical examination to diagnose you. Prof Imam might ask you to perform a series of exercises to complete the diagnosis, such as placing the hand open on a table or flat surface to see if you can fully stretch your fingers.

None are usually required as the condition is straightforward to diagnose.

Non-operative treatment
Percutaneous needle fasciotomy
This is an outpatient procedure that is performed under local anaesthetic. Once numb, the surgeon uses a small needle to cut the diseased cords through a tiny needle hole. We performed this procedure many years ago, but Prof Imam largely abandoned it due to a high recurrence rate. It does, however, have its place, and some surgeons use this as a first-line treatment.

Collagenase enzyme injections 
In 2012, a new enzyme injection called Xiapex was released in the UK to dissolve the Dupuytrens disease. Hand surgeons have been using Xiapex since its UK launch.

Unfortunately, the manufacturer has removed Xiapex from clinical use on commercial grounds and is unavailable for Dupuytren’s disease in the UK.

Radiotherapy
Radiotherapy has been used for many years to that Dupuytren’s disease. It is widespread in Germany. The treatment is only indicated for early disease in the palm with no flexion contracture of the fingers. Treatment consists of daily radiotherapy for five days followed by a five-week break and then daily treatment for five days. The risks associated with radiotherapy are redness and dryness of the palms and a theoretical risk of causing a malignancy, although no cases have ever been reported. The room is quite large for the machine but painless. It is not a common practice in the UK. 

Operative treatment
The surgery is performed as a day case procedure under local or general anaesthetic. The surgery takes between 30 and 60 minutes, depending upon how severe the condition has become. A tourniquet is not usually used if the procedure is performed wide awake with a local anaesthetic.
The surgery is performed through a zigzag type incision in the palm and along with the finger. The skin flaps are elevated, and great care is taken not to injure nerves and blood vessels to the finger. The Dupuytren’s disease was removed. Occasionally in more advanced cases, a skin graft needs to be placed over the wound. The skin is taken from the forearm or groin (for larger grafts). The tourniquet, if used, is then released and any bleeding controlled. The skin is sutured with absorbable stitches, and a bulky dressing is applied with a Plaster of Paris slab for immobilization.
In all my cases, the skin sutures are dissolvable and avoid the painstaking and uncomfortable removal of the inserted tiny stitches.

Post-operative rehabilitation
The local anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first five days to prevent the hand and fingers from swelling. My preference is to remove the dressing between 2 and 3 days. The wound is cleaned and redressed with a simple dressing and kept covered for 7-10 days. Early motion is encouraged. The skin stitches are usually dissolvable and dissolve over a 2 to 4 week period. The therapist will apply a resting night-time splint that should be used at night for six months. 

Return to activities of daily living
It is my advice to keep the wound covered, clean and dry for about ten days.

Return to driving:
The hand needs to have complete control of the steering wheel in case of an emergency. Return to safe vehicle control varies between individuals, but patients can often drive within the first week.

Return to work:
Everyone has different work environments.
Early desk-based activities may resume immediately, but returning to heavy manual labour should be prevented for approximately 4 – 6 weeks. Would you please ask your surgeon for advice on this?

Complications
Overall more than 95% of patients are happy with the result. However, complications can occur.
There are complications specific to Dupuytren’s surgery and also general complications associated with hand surgery.

Specific complications:
Recurrence: the disease will always recur; however, most patients have a long-lasting result that they are happy with. 
Failure to completely straighten the finger (particularly after the 2nd and 3rd-time surgery or advanced disease).

Injury to the blood vessels and nerves to the finger (very much less than 1%) may leave one side of the finger numb. If this occurs, the wound should be explored, and if injured, the nerve repair.

There are risks of skin grafting rejection if used.

Further reading:

Dupuytens Contracture