Dupuytren’s Disease

What is Dupuytren’s disease?

Dupuytren’s disease is a common condition caused by thickening of the tissues of the palm. It affects about one in ten males over the age of 65 in Northern Europe.  The typical symptoms are initially some thickening in the palm particularly in the line of the ring finger. In the early stages there are usually few symptoms although some patients have discomfort with gripping due to pressure on the nodule. As the condition progresses flexion contractures occur i.e. the finger becomes bent towrds the palm and cannot be straightened fully. When the patient can no longer easily place their hand flat on the table then treatment should be sought.

Why does it occur?

The pathology i.e. the abnormality is a fibrous thickening of the normal fibrous structures in the hand. Nodules and then bands form under the skin. In time these contract preventing straightening of the fingers and sometimes the thumb. Dupuytren’s disease can present as thickenings on the back of the middle joints of the fingers (PIP joints) and even on the sole of the foot. Both of these rarely need significant treatment. There is a strong inherited tendency particularly in Anglo-Saxon populations although many people report no familial problems. It is thought to be related to Viking genes. It is rare but recognised in Asian and African races. In many people there is no obvious initiating cause i.e. something that starts the condition. In some patients it follows an injury. There is a strong link with smoking and a disputed link with heavy drinking.

What happens if nothing is done?

(This is referred to as the natural history i.e. what happens if Nature runs its own course.)

Most people develop gradually increasing contracture. Resolution is very rare and mainly associated with central neurological (brain) injuries. In most people there is a gradual progression over years from a thickening in the palm or base of a finger to a band which may be quite discrete or rather diffuse in the finger. The affected finger(s) or thumb gradually contracts down into the palm. The rate of progression of the disease is very variable. We have studied nearly 60 patients and shown that once a contracture has started it progresses at an average of 60 a year in the first joint of the finger (MP joint) and 70 a year in the second joint of the finger (PIP joint). The range is very variable between 0 and 900.

Making the diagnosis

The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at the wrists and hands and will usually record the degree of stiffening (contracture) with a special ruler to measure angles (goniometer). They may examine the patient’s feet to look for foot(plantar) nodules.

What test(s) might be performed?

Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology

In Dupuytren’ disease usually no tests are requires, rather this is a clinical diagnosis made by an experienced Hand specialist based upon the history of the problem and the examination of the hand.

Treatment:

What are the non-operative treatments?

Treatment should ideally start with non-operative options but in Dupuytern’s there is no known treatment that will prevent the onset or progression of the disease. Stretching the fingers seems to make no difference.

What are the operative (surgical) options?

There is no treatment that can prevent Dupuytren’s contracture, or always stop it recurring after surgery.  It is best to avoid surgery at the early stage where nodules are present but the fingers are not yet contracted.  In some cases the surgery can act as a trigger to more rapid spread of Dupuytren’s in the hand.

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 by your Hand specialist.

There are 3 main surgical options called fasciotomy, fasciectomy and dermo-fasciectomy:

Fasciotomy: The most straightforward operation is known as a “fasciotomy”.  It is also known as needle fasciotomy or needle aponeurectomy. This is suitable where the contracture is mainly in the palm, rather than in the fingers.  It involves an injection of Local Anaesthetic, and a small (<5mm) incision in the palm, then dividing the cord of tight tissue that is stopping the finger from straightening.  The wound in the palm heals without stitches over 2-4 weeks. The hand may be immobilised inplaster for about 7-10 days and then the hand will be mobilised ie used, with a plastic splint used at night for three to six months to help maintain the correction of the contracture. Our research suggests that an injection of steroid in the palm at six weeks from surgery may help reduce the risk of recurrence. This operation is almost risk-free and easy to “get over”.  The main downside is further contracture developing and requiring another operation in 50% within 5 years.

Fasciectomy: If the contracture is more extensive, then a “fasciectomy” may be recommended.  This is the commonest operation for Dupuytren’s contracture but it is a much more involved operation.  This may be performed under a Local Anaesthetic, Regional Anaesthetic (numbing the wrist and hand or the whole arm) or General Anaesthetic. Generally we try to perform surgery under local/regional anaesthetic where possible (see sheet on Anaestheia). The finger(s) are opened up via zig-zag shaped incisions which helps to prevent scar problems, and the affected tissue in the hand and fingers is cut away.  Wounds in the palm are partly unstitched as this heals better, wounds in the fingers are mostly stitched.  A plaster of Paris splint is applied.

Dermo-fasciectomy: In some “re-do” cases or other special situations such as very aggressive disease or in a young patient, a “dermo-fasciectomy” may 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, to protect the graft. The skin graft helps reduce the risk of recurrence ie the Dupuytren’s tissue returning, but at the expense of a more complex operation.

In the Hand to Elbow clinic, we have been pioneers of Day Case surgery for all types of Dupuytren’s surgery.  You will usually be in hospital for part of the day, or occasionally over one night.

What happens in the next few weeks?

The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthtic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.

The hand will be in a plaster splint and a bulky dressing. At the first clinic visit this will be removed, the dressings changed and physiotherapy started. The Hand specialist and the physiotherpist will instruct the patient in use of their hand. The key is long slow steady stretches avoiding pain. This is assisted by the night splint which helps keep the finger(s) stretched out at night. First thing in the morning the finger(s) should be straight but rather stiff. Gentle stretches will start getting the hand going. This is helped by putting the hand in warm water once the wounds have healed (usually by 2 weeks).

Movement:

Gradually the movement in the finger will return. The patient should aim to maintain enough straightening (extension) to be able to get the hand flat on the table whilst gradually increasing bending (flexion). Typically the fingertip should start reaching the palm within 2-3 weeks of surgery and regain nearly all flexion by 5 weeks or so following surgery. Most of the movement gained following surgery occurs in the first 6 weeks and this time must be used productively to ensure a good result. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day.

Swelling:

The finger(s) will be swollen for several months.The quicker the swelling starts to reduce the better particularly to help improve the movement.This is best achieved by elevation of the hand especially for the first 2 weeks but preferably for at least 6 weeks. Iceing the finger and avoiding pain whilst stretching helps.

Pain:

It is a fine balance between stretching enough to make progress and doing too much and iritating the finger so that it becomes swollen and painful. If that happens the finger should be rested and elevated before once again starting movement.

Use

Your hand can be used for normal activity after the plaster is removed.  Most patients can drive after a 3-4 weeks.  Most patients return to light work in 2-3 weeks, but this varies with occupation; heavy manual work usually takes at least 6 weeks. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. If this is marked a Physio may be organised to help reduce the scar tenderness but this is rarely required. Patients should avoid pressing heavily on the scar for 3 months following the operation as this will be quite painful. Examples of activities to avoid are using the palm to grip/twist a heavy or tight object or use the palm to help get out of a chair.

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.  The aim of surgery is to improve hand function allowing it to go flat on a suface e.g. a table and to bend fully or nearly fully. We achieve this in > 90% of cases although contracture although for contractures of the middle joint of the finger (PIP joint) there is usually a residual contracture which is compensated by over extension of the first joint of the finger (MP joint). Overall the outcome tends to reflect the severity of the cases i.e. more severely contracted fingers will have poorer results.

Are there any risks?

All interventions in medicine have risks. In general the larger the operation the greater the risks. For Dupuytren’s surgery  the risks include:

  • It is sometimes not possible to fully straighten the finger, especially if there has been a severe (over 60°) or long-standing contracture in the middle joint of the finger (PIP joint).
  • There is a small (~1%) risk of wound infection, which almost always settles well with antibiotics.
  • Stiffness may occur in particular in the fingers.This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below)
  • There is a small (<1%) risk of damage to a nerve in the finger, leading to permanent numbness. In first off cases (i.e. not redo operations) we have had no incidences of permanent nerve injury in the important tip of the finger in the last 5 years
  • 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. This has never occurred in our practice.
  • Scars may be tender initially but usually settle with scar massage, over 3 months. If they are not settling specific desensitisation exercises from the physio should settle the problem.
  • 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. The donor site i.e. wherethe graft came from, occasionally is a little tender or numb but this is rarely a significant problem.
  • There is an approximately 25-50% chance of further contracture requiring further surgery in the same area.
  • Any operation can have unforeseen consequences and leave a patient worse than before surgery. This is rare for CTS.