Dupuytrens Disease causes thickening to the tissues of the palm which may interfere with the funcyion of the hand

DUPUYTREN'S CONTRACTURE 

WHAT IS DUPUYTREN'S CONTRACTURE?

Baron Dupuytren put his name to this condition in the early part of the 19th century, but it had been recorded long before that. It involves ‘nodules’ and ‘cords’ developing in the palm and fingers, causing the fingers to curl up. The abnormal tissue develops in the sheet of fibrous tissue that lies beneath the skin of the palm, with extensions into the fingers and thumb. Fibres of this palmar fascia run in all directions, but the longitudinal ones can shorten and pull the affected finger(s) into a flexed position. The abnormal tissue does not involve the tendons that bend the fingers which can function normally once the contracting bands are removed as long as the joints are still mobile.  

HOW DOES THE CONDITION PROGRESS?

The condition most often starts with a firm knot (nodule) in the skin of the palm. This may stay the same for months or years, or it may progress to the next stage in which cords of fibrous tissue form in the palm and may run into the fingers or thumb, pulling them into a flexed position. There is great variation in the rate of progress, but it is usually possible to distinguish the more aggressive form of the disease early on. The fingers furthest from the thumb are most frequently affected. In severe cases it can affect other parts of the body, most often the feet, but this produces an uncomfortable lump on the sole instead of toe contractures.  

WHAT CAUSES DUPUYTREN'S CONTRACTURE?

The cause of Dupuytren’s contracture is not fully understood. There may be a family history, and in some cases it appears to come to the patient’s attention after an injury or operation, but it is debatable whether these can be regarded as a sole cause. Patients with certain other conditions have been found to be more likely to develop Dupuytren’s contracture, but this does not mean that they cause it, nor that people with Dupuytren’s are likely to develop other illnesses. The conditions where there has been found to be an association include diabetes, epilepsy (possible due to the drugs that are used), and liver disease, possibly associated with high alcohol intake.  

WHAT TREATMENT IS AVAILABLE?

Once a contracture has developed to an extent that interferes with function, surgical excision of the contracted bands is generally felt to be the most appropriate treatment. In some patients there may be a case for less invasive methods. Needle fasciotomy has gained some popularity because of its simplicity and the lack of a wound to heal, with rapid recovery. However it is important to appreciate its limitations and risks.  

WHAT DOES SURGERY INVOLVE?

Open surgical treatment is known as fasciectomy. This can usually be done under local anaesthetic (axillary block), with the patient awake, as a day case. Incisions are designed according to the position of the bands, but usually take a zig-zag line to avoid straight scars running longitudinally. The abnormal tissue is removed taking care to avoid damage to nerves and arteries running into the fingers. This can be very difficult especially when there has been a previous operation, but every effort is made to protect them.  

WHAT RISKS DOES SURGERY HAVE?

Division of a nerve in the finger results in loss of feeling on one side of a digit. It is not always possible to restore full straightening to finger joints, even when all abnormal tissue is removed, because of tight ligaments which cannot always be released. Part of the incision may be deliberately left open in a crease in the palm; this allows freer movement and avoids collection of blood under the skin of the palm. It heals as well as if it had been stitched.  

WHAT IS THE RECOVERY LIKE?

After operation the hand is rested in a splint and bandage, and elevation in a sling at all times reduces swelling. The healing wound does require regular dressing changes in the two weeks after operation. Within this time a smaller splint is fitted and the hand mobilized. The splint should be worn at night usually for up to six months. Most patients regain movement without too much difficulty, although determination and persistence are needed. Once the wound is healed, physiotherapy may be required once a week for up to two months, or sometimes more. A small proportion of patients have difficulty moving, and can have a stiff hand for some weeks or rarely longer. This is not possible to predict. A few patients develop a condition called reflex sympathetic dystrophy with sweating, stiffness and sensitivity to cold. When this occurs extended treatment including drugs and physiotherapy may be required.  

CAN DUPUYTREN'S CONTRACTURE COME BACK EVEN AFTER SURGERY?

Dupuytren’s contracture is not a fully curable condition. Eventually recurrence is likely in some form, elsewhere in the hand or in the same area, but the correct approach is to maintain function and mobility as far as possible, accepting that further surgery may eventually be necessary.