Dupuytren's Disease
What is Dupuytren’s contracture?
Dupuytren’s contracture is a condition in which there is a thickening of the tissues in the palm and in the fingers and thumb.
What are the various manifestations of Dupuytren’s contracture?
Dupuytren’s contracture can manifest in any of the following ways:
- A nodule in the palm or digits
- A pit in the skin of the palm or digits
- A cord in the palm or digits
- A extension of a cord from the palm into the fingers resulting in an inability to fully straighten the joints of the fingers or thumb.
What are the symptoms of Dupuytren’s contracture?
In addition to an inability to straighten the fingers completely the nodules or cords of Dupuytren’s contracture can occasionally be painful. The restriction of mobility and abnormal position of the fingers is socially inhibiting especially when shaking hands.
Function of the hand can be significantly affected by advanced Dupuytren’s contracture as the hand cannot be slid into narrow spaces or into pockets, there is difficulty in picking up change or small objects and quite often patients complain that the fingers stick into the nostrils or face while washing.
Due to the fact that the fingers are significantly bent it becomes difficult to grip large objects or to develop a strong power grip.
A variant of Dupuytren’s contracture is known as Lederhosen’s disease, which presents with similar findings but in the foot. In men, a similar contracture can occur in the penis. This condition is known as Peyronie’s disease. This causes problems with painful deviation of the penis on erection and makes intercourse difficult.
What is the treatment of Dupuytren’s contracture?
The treatment of Dupuytren’s contracture depends upon the extent and severity of the problem.
Very early disease in the form of either a nodule or a small cord which does not cause pain or affect hand function does not need to be treated.
If the contracture is painful or if there is a restriction of mobility (inability to rest the hand flat on the table is considered as a reasonable indicator for deciding to have surgery) or an inability to use the hand normally due to the contracture are indications for surgery.
If the skin overlying the nodules and cords is not affected a procedure known as a simple fasciectomy suffices.
If however, there is significant skin involvement with the disease, the diseased skin has to be excised and a procedure known as dermofasciectomy with a skin graft is required. The use of a skin graft is protective against future recurrences in most cases.
In the event that there is a severe contracture of one of the joints of the finger or a difficult recurrence, a two stage procedure which involves the use of a device called an external fixator in the first stage to straighten the finger followed by a dermofasciectomy and a full thickness skin graft is required.
What problems can occur following surgery for Dupuytren’s contracture?
Just like any other operation surgery for Dupuytren’s contracture can have post operative problems such as bleeding, haematoma formation, infection or delayed healing of the wound.
The sensation at the tips of the fingers can change, the scars can be tight and in time patients can develop a recurrence at the site of surgery or new disease may develop in other parts of the hand which is unrelated to the part that has been operated upon.
The use of a full thickness skin graft is usually protective against a recurrence in the operative area in most cases.
What is the normal post operative course?
Most patients will have fine stitches placed in the skin and the hand is placed in a plaster splint. The splint is removed in the week following surgery by the Hand Therapist who then prepare a plastic splint to keep the fingers and thumb stretched. This plastic splint is normally worn at night after the first two weeks and the hand is free during the day to exercise and to use for day to day activities. The plastic splint is normally for a period of six months following surgery.
In the event that a full thickness skin graft has been used the first dressing is done at seven to ten days following surgery and the rehabilitation and mobilisation programme is conducted at the slightly slower pace than in a simple Fasciectomy in order to allow the skin graft to heal.
Patients who have an external fixator applied for severe or recurrence contractures care shown how to care for the fixator both in terms of cleaning and maintaining mobility of the joints. The second operation which involves a dermofasciectomy and a skin graft is usually scheduled four to six weeks following the application of the external fixator when the finger has been completely straightened. The subsequent management is similar to a patient who has an ordinary dermofasciectomy and skin graft.
