Dupuytren's disease (also known as Dupuytren's contracture) is a condition whereby there is an overgrowth of the cells just below the palm skin leading to thickened nodules and cords within the palm and a progressive contracture (flexed posture) of the fingers. More often the little finger is the affected digit but any finger or the thumb can be involved. The condition is relatively common affecting almost one in ten Northern European males over the age of 65 but it can present in adult men and women at any age.
Since the condition was first treated by Baron Guillame Dupuytren in 1831 there has been considerable research in to the causes and treatment of the disease. Some causation theories have stood the test of time whereby others have been discarded due to lack of supporting science. What we do know is there is strong genetic (familial) predisposition to the condition but other factors may contribute to starting the disease in susceptible people. Examples of these include smoking, alcohol, liver disease, diabetes, epilepsy and injuries to the hand.
Dupuytren's little finger
The condition can also lead to thickened pads on back of the finger joints known as Garrod's pads. An identical condition can also affect the sole of the foot (known as Ledderhosen's disease) and the male penis (known as Peyronie's disease).
Garrots pads - Dupytren's thickening on the back of the finger joints
Treatment Options for Dupuytren's Disease
Due to the fact that the underlying cause of Dupuytren's is genetic no treatment can cure or prevent the condition and sadly recurrence is possible after any treatment method. It is best to avoid surgery in the early stages where nodules are present but the fingers are not yet contracted because in some cases the treatment, in particular surgery, can act as a trigger to more rapid spread of Dupuytren's in the hand.
Multiple treatment methods have been described but to date despite articles in the popular tabloid press there is no evidence to support the use of oxygen, ultrasound, or radiation in the treatment of Dupuytren's.
There is growing evidence to support the use of a special injection of an enzyme called collagenase into the palm and early clinical trials are encouraging. This can be discussed further at the Hand Clinic as this treatment is still experimental and is only indicated in specific cases.
To date the only reliable and predictable method of treatment is surgery and once a contracture has reached the stage where the hand can no longer be placed flat on the table, or the finger is "getting in the way", then it is usually time to consider an operation. There are more precise measurements that guide us in this assessment that will be done at The Hand Clinic.
Surgery for Dupuytren's Contracture
In essence the options available are to simply divide the thickened cord of tissue (fasciotomy), to divide and remove the thickened cord (fasciectomy) or to divide and remove the thickened cord and the overlying involved skin (dermo-fasciectomy).
The most straightforward operation is known as a "fasciotomy". This is suitable where the contracture is mainly in the palm, rather than in the fingers. It involves a Local Anaesthetic injection, and a small incision in the palm, then dividing the cord of tight tissue that is stopping the finger from straightening. An alternative method is to use a needle through the skin to divide the cord and this can be done in the Hand Clinic itself if indicated. The wound in the palm heals without stitches over 2-4 weeks and a plastic splint is occasionally used at night for three months. This operation is almost risk-free and easy to "get over". The main downside is the risk of a further contracture developing requiring another operation is 50% within 5 years.
If the contracture is more extensive, then a "fasciectomy" may be recommended. This is a much more involved operation. It may be performed under a Local Anaesthetic, Regional Anaesthetic (numbing the whole arm) or General Anaesthetic. Zig-zag shaped incisions are used in the hand to prevent scar problems, and the affected tissue in the hand and fingers is cut away. Wounds in the palm are not stitched as this allows better healing; wounds in the fingers are stitched. A plaster of paris splint is applied for the first two weeks.
In special situations such as very aggressive disease and young people or in "re-do" cases when surgery has been performed previously, a "dermo-fasciectomy" will be recommended. This involves removing some of the skin of the finger, as well as the Dupuytren's tissue. The skin is replaced with a skin graft, taken from near the elbow or wrist. This area is sewn up directly. The skin graft is sewn to the finger wound with dissolvable sutures. The finger will be kept still with the plaster splint for at least a week but probably two, to protect the graft.
In Bath, we have been pioneers of Day Case surgery for Dupuytren's fasciectomy so you will usually be in hospital for only part of the day or occasionally over one night depending on your general health.
In the next few weeks
It is extremely important to keep the hand elevated high for the first 48 hours, usually on pillows. The hand will be in a plaster splint. At the first clinic visit this will be removed, the dressings changed and physiotherapy started. After 2 weeks, the stitches will be removed by the practice nurse or physiotherapist if necessary. Depending on your individual needs a plastic splint will be made to measure and may be required for up to 3 months but at night only. You can discuss this further at the Hand Clinic with your surgeon and therapist.
What are the results of the operation?
Most patients say they have a good result following this operation, with better hand function, and no deformity or less deformity.
Are there any risks?
- It is sometimes not possible to fully straighten the finger, especially if there has been a severe (over 60°) or long-standing contracture.
- There is a small (~1%) risk of wound infection, which settles with antibiotics.
- There is a small (~1%) risk of damage to a nerve in the finger, leading to permanent numbness.
- There is a tiny (<1/1000) risk of losing the circulation to the finger, which may lead to amputation of part of the finger. This is higher in smokers and in re-do surgery. Your surgeon will advise you if your finger is at particular risk.
- Scars may be tender, and there may be some stiffness. Both of these are treated with physiotherapy.
- Chronic Regional Pain Syndrome "CRPS". This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand "over-react", causing swelling, pain, discolouration and stiffness, which very slowly improve, but may leave stiffness. This is treated with physiotherapy, and sometimes tablets.
- If a skin graft was needed then there is a small chance that this will not "take". Usually this is only a small area, and can be treated with dressings. Very occasionally the graft would need to be repeated.
- There is an approximately 25-50% chance of further contracture requiring further surgery in the same area. The risk is very individual so this will be discussed at the Hand Clinic.