Dupuytren’s Contracture
Dupuytren’s contracture is a common hand condition. It is characterized initially by palmar nodules followed by development of fibrous cords. In many patients, the fibrous cords gradually contract resulting in finger flexion deformity. If left untreated, most fingers eventually become permanently bent, impairing such daily activities as shaking hands, wearing gloves, and placing one’s hand in a pocket. Fortunately, if treated in the mild to moderate stages of contracture, the results are usually good to excellent and frequently last many years.
What is Dupuytren’s contracture?
Dupuytren’s contracture is a benign hand condition involving fibrous tissue in the palms. In the more severe cases, it affects the back surface of the middle joints of the fingers (Garrod’s nodes), soles of the feet (Lederhosen), and the penis (Peyronie’s). It is usually painless, although early in the disease process there may be some tenderness when gripping objects strenuously. Dupuytren’s is almost exclusively in Caucasians and is thought to have originated in Northern Europe. It is also more common in men and usually starts after age 50, although more severe cases occasionally occur in the fourth or fifth decades. If there is a family history of Dupuytren’s, onset at an early age, and involvement in several locations, there is a greater likelihood of more severe contracture and greater risk of recurrence after surgical excision. Trauma and repetitive strain of the hands have not been shown to cause Dupuytren’s.
When should a hand surgeon be consulted?
- If the diagnosis is uncertain. Some cysts and nodules can mimic Dupuytren’s disease. The diagnosis is usually obvious to a hand specialist, and there is rarely any need to perform a biopsy or other tests.
- Once a finger contracts to the extent where the palm cannot be placed flat on a table top (called the “table top test” in the image below), then it is usually time for treatment. If the finger joints have contracted severely, then it will be impossible to regain full range of motion regardless of the treatment type. Also, when treated earlier, excellent results are easier to achieve and less therapy is required. Keep in mind, however, that no treatment is required until the contracture prevents flattening of the palm on a flat surface.
What are the treatment options?
The goal of treatment is to remove or break up the contracted cords to allow for improved finger range of motion. There is no medical or surgical cure for Dupuytren’s disease. There are three main techniques currently used:
1. Surgical excision (Dupuytren’s fasciectomy): This is typically performed under a regional block anesthetic as an outpatient. This procedure often provides good to excellent results in patients with mild to moderate joint contractures.
- Fasciectomy with Z-plasties: This variation in the skin incisions provides extra length to the contracted skin and breaks up the longitudinal orientation of the dermis, thereby facilitating recovery and decreasing the chance of recurrence of the contractures.
- Dermatofasciectomy with skin grafting: This surgical technique involves excising the skin overlying the most prominent Dupuytren’s nodules. This procedure is often used in patients with more severe forms of the disease and decreases the chance of recurrence. A skin graft, usually an inch or two in size, is taken from the same arm.
2. Needle aponeurotomy (percutaneous fasciotomy): This procedure technically is a fasciotomy where the Dupuytren’s cord is cut with a needle but not excised. This is usually an office procedure performed under local anesthesia. It is particularly useful when the primary contracture is in the palm or when a patient is taking anticoagulant medications (blood thinners) and cannot have surgery. Needle aponeurotomy is more difficult and there is a higher risk of nerve injury when performed in the finger. Recurrence is common with this technique, but it is a simple and inexpensive technique that can give some relief for a few years and may be repeated for recurrent contractures. Unfortunately, most cases of Dupuytren’s contracture have large nodules and cords in the finger where the needle technique may have excessive risks.
3. Collagenase enzyme injection: In 2010 the FDA approved Xiaflex, a collagenase enzyme injection used to help dissolve Dupuytren’s cords. The indications are similar to those of needle aponeurotomy (see #2 above). The injection is performed in the office and the cord is manually “popped” by the surgeon in 1 or 2 days. Although the period of time before a contracture recurs is unpredictable, to date many patients have had greater than two years of relief following collagenase injections. Xiaflex collagenase injection is the only FDA approved non-surgical treatment option for Dupuytren’s contracture. Not all patients are candidates for this injection. Possible complications from collagenase injections include: tendon ruptures, skin tears, and lymph node reactions. Xiaflex is now available for use at the Raleigh Hand Center.
What is the recovery from surgery?
Following Dupuytren’s fasciectomy surgery, the patient is discharged home on the same day (outpatient surgery). Hand elevation is advised. A splint may be worn the first few days at which time the dressing is changed in the office and gentle finger range of motion exercises are begun. A removable splint is typically worn at night for a period of weeks and sometimes months depending on the severity of the contractures. At two weeks the sutures are removed and the patient may then wash the hand. At that time, patients are allowed to perform most everyday activities without excessive strain. At four weeks most patients can resume full activities including sports and strenuous use of tools.
What are the complications from surgery?
As with any surgery, there is a small risk of infection and difficulty with wound healing. Fortunately, this is not common with Dupuytren’s surgery. Most patients have some degree of swelling and stiffness requiring hand therapy with exercises to be continued at home. Occasionally, particularly in the more severe or recurrent cases, one of the digital nerves that carry sensation to the fingertips can be injured resulting in loss of sensation in the finger.
Images and video provided by American Society for Surgery of the Hand. The material provided is intended for general information only and does not constitute medical advice. This does not replace direct evaluation by a physician.