Dupuytren’s disease

What is Dupuytren’s disease?

Dupuytren’s disease is a benign, progressive condition in which fibrous layer of tissue underneath the skin of palm and fingers are affected. This disease leads to the thickening of the tissue leading to nodules, that could then progress to tightening of the fascia resulting in cords, pits causing inward pulling of fingers towards the palm. This happens gradually over years or in some cases months and is also known as Dupuytren’s contracture. It usually affects small and ring finger.

It affects mostly men of the age 50-70 years. Caucasian males of northern European descent (Viking’s disease) are commonly affected by this condition. It runs in families. Its exact cause is not known, however there are few factors that can lead to the development or progression of the Dupuytrens contracture. It is often associated with diabetes, high alcohol intake, smoking, liver disease and seizure disorders such as epilepsy. Though there were reports of Dupuytrens disease following hand or wrist injury, there is no scientific evidence to prove this. In the United Kingdom, more than 2 million people are reported to develop this condition.

 

What are the symptoms of Dupuytrens disease?

Dupuytrens disease is a form of hand deformity that usually develops gradually over a span of years. It involves the following signs and symptoms-

  • Nodules- one or more small lumps or nodules can develop in your palm. They are usually fixed to the skin. Initially, they are tender and painful which may go by the time. In some cases, there can be pitting of the skin over the affected area.
  • Cords- the thickened fascia with time contract together to form cords under the skin which limit the movement of the fingers and thumb. You cannot straighten or spread the fingers and thumb.
  • Contractures- with the contracture/shortening of the cord, fingers may be pulled towards your palm and may overlap each other. It commonly involves ring and little fingers, but it can also affect other fingers even all the fingers of the hand including the thumb. You may feel difficulty in grasping large objects, and in performing simple activities like putting on gloves or shaking hands, washing your face, holding coins in hand etc. In some rare cases, the disease may cause similar thickening in the feet or penis.
  • Garrods Pads or Knuckle pads – Lumps on the backside of finger joint, most of them are asymptomatic, however in some patients they become thick and the skin loses elasticity.
  • When the condition progresses and starts interfering with hand function, then Dupuytren’s disease surgery becomes necessary.

 

How is it diagnosed?

Your orthopaedic surgeon will investigate your medical history, general health and family history. He will examine your palm to record the location of nodules and cords and will observe its impact on the range of motion. He will measure the contracture in your finger and compare them with other measurements throughout the treatment. This helps to understand the progress of the disease. In some patients your surgeon may ask for ultrasound scan to rule out other pathologies.

 

What happens if nothing is done?

If it is left untreated, your disease will progress further and your affected finger will become more flexed (bend). You will not be able to straighten the finger at all. You may lose the function of the involved finger and even the entire hand.

 

How is it treated?

Most patients do not need treatment in cases where disease proceed slowly and do not cause pain or deformity for many years. Dupuytrens disease is not curable and intervention is needed when the condition progresses and starts interfering with hand function.  It can be treated conservatively or surgically. Conservative methods include steroid injections, needle technique, enzyme injections and physiotherapy.

Surgery is indicated in

  • Contracture of metacarpo-phalangeal joint (palm meets finger) of more than 300
  • Any contracture of interphalangeal joint (finger joints).
  • Contracture between thumb and index finger (1st web space) reducing the hand span
  • Severe, diffuse disease
  • Multiple joint involvements
  • Marked reduction in the hand function
  • Recurrences
  • Shortening of the ligaments
  • Fibrosis of structures like volar plate

 

What are the non-operative treatments?

Non-operative treatment includes-

  • Steroid injections– anti-inflammatory medicines such as corticosteroids are injected directly into the affected areas that have painful nodules. It may help with the pain and improve grip strength. However, it is not always effective for every patient.
  • Use of Splint – it is not known to provide any relief in the Dupuytren’s contractures. It cannot slow down the progress of the disease. Forceful stretching of the contractures in the finger can injure the finger more and accelerate the progression of contracture.
  • Needle aponeurotomy– during this procedure, local anaesthesia is given to numb your hand and a sharp end of the hypodermic needle is introduced into the cords to break the fibrous tissue and the tissue is lengthened. It can be done in more than one finger at a time.
  • Enzyme injection– an enzyme collagenase derived from clostridium histolyticum is injected into the cord to make them soft and weak. Then, your surgeon will manipulate your hand after 24-72 hours so that your cords in your hand are broken and fingers can be straightened. It is usually done under local anaesthesia.
  • Hand therapy– The hand therapists will teach you exercises to prevent stiffness, regain the normal range of motion, and restore strength and function of the finger. Besides they will also apply a splint. Based on the severity of pre-op contracture the hand therapist/surgeon will advise you regarding the use of splint. You have to wear the splint during sleep at night for few months after the procedure.

 

What does the operation involve?

Surgery is usually performed when the contractures built in your palm interferes with the normal function of the hand. The main aim of surgery is to correct the deformity, reduce the contracture, and restore the function of the hand by removal or disruption of the cords.

  • The operation is conducted as a day case under local or general anaesthesia. Most patients are discharged on the same day.
  • The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
  • Procedure- after anaesthesia, you are given antibiotics to protect you from any infection during and after the surgery. The incisions are made according to the type of surgery selected for the condition.
  • In fasciotomy, a needle is used to cut the cord or a small cut is made on the skin and the cords cut with scalpel, the cords are not removed and they are just divided to straighten the fingers.
  • In fasciectomy, the skin is cut in a zigzag manner along the natural creases of the hand and the affected cord and damaged tissues are removed. In some cases, the skin gets damaged and lost due to the cords, dermofasciectomy is done for this. In this procedure, the skin is removed with the affected cords. A skin graft is used to replace the skin. The skin is usually grafted from your upper arm or forearm. The wound is closed with thin non-absorbable sutures and the wound is left open to allow healing.
  • The surgical time for the operation is 1-3 hours depending on the complexity.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; some patients may remain in the hospital overnight. Patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • You will have a plaster (Plater of paris – half cast) with the fingers in the corrected position for 10-14 days.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check, removal of stitches and hand therapy.
  • The hand therapists will teach you exercises to prevent stiffness, regain the normal range of motion, and restore strength and function of the finger. Besides they will also apply a splint. Based on the severity of pre-op contracture the hand therapist/surgeon will advise you regarding the use of splint. You have to wear the splint during sleep at night to avoid contracture of the finger.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).

 

Are there any risks?

  • Sloughing or necrosis of wound edge
  • Temporary numbness and tingling (neuropraxia) due to stretching of nerves. Injury to nerves and blood vessels (<5%)
  • Lack of blood supply to the fingers
  • Stiffness and swelling of the wound
  • Infection(<5%)
  • Flexion contracture
  • Recurrence
  • Scarring
  • Need for skin grafting
  • Stiffness and instability of finger
  • Complex Regional Pain Syndrome (<1%)
  • Hematoma that may result in necrosis (19%)

 

What are the results of the operation?

The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on grade and severity of the contracture and adherence to handtherapy. The outcome is very predictable under the experience of the author.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 6 weeks if your job involves physical work. You should be able to resume driving in 2-4 weeks. The above time line could vary based on the severity of the contracture and the treatment modality.  Your physician will be able to advise you.

Dupuytrens disease surgery_1

  1. Severe Dupuytren’s contracture affecting all 5 fingers causing severe disability
  2. Post -surgery, the patient regained almost normal function back in his hand

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