In 1831, French surgeon Baron Guillaume Dupuytren first described a spontaneous, "deep scarring" disorder of the palmar surfaces of the hands and fingers....
The skin of the palmar surfaces of the hands and fingers is special. Like the skin of the soles of the feet, this skin...
- lacks hair
- is thick and tough
- is very sensitive
- has grooves and whorls (fingerprints) to help with gripping
This special glabrous skin is supported by an underlying network of tough palmar fascia.
Pathology - Dupuytren's Disease
In Dupuytren's Disease, for unknown reasons, parts of the supporting palmar fascia become progressively thickened. This frequently distorts the overlying skin, leading to nodules and/or pits. The fascia can even pull longitudinally to limit the extension of a finger at the various knuckles.
The course of Dupuytren's Disease is unpredictable, but there are some consistent truths....
- The process is not malignant.
- The disease may progress slowly, or it may have periods of temporary arrest followed by rapid progression.
- Involvement of the feet may be associated in 15-20% of cases. Other body parts (such as the penis) may also be affected.
- Bilaterality is common.
- Flexion contractures usually occur at either of the first two finger joints.
- Flexor tendons are never involved in this process.
- Skin may be involved by the infiltration of dermal layers.
- Recurrence is frequent, particularly at the proximal interphalangeal joints.
- This condition is not painful, except for tenderness in the area of skin infiltration or during an inflammatory phase.
Dupuytren’s contracture is a condition commonly found in northern European countries, such as Scandinavia and Russia. There is a strong familial tendency to develop Dupuytren’s Disease, and some have proposed that the condition is a result of a single dominant gene. Men are much more commonly affected than women.
Signs and Symptoms
- The most common evidence of the disease is a “lump” or nodule in the palm near the flexion crease, most often located at the base of the ring or small finger.
- This lump or nodule may also occur at the base of the thumb.
- Although the appearance of these nodules in the finger usually occurs within the course of the disease, these nodules may be evident as the very first symptom.
- Another sign or symptom of Dupuytren’s contracture is known as a dermal pit.
- The pit may be single or multiple, and appears as a small, local, deep indentation of the skin.
- This may be the first finding, it may come later, or the pit may never appear at all.
- The pit usually is located in the palm but also can be found in the fingers.
- This indentation occurs due to a contraction of the connective tissue fibers from the palmar fascia to the skin. The skin is drawn down to form the pit.
- The cord is a longitudinal fibrous band, which extends from the palm into the finger(s).
- It most often appears with a nodule, but it can be separate.
- It may appear as a single or multiple bands.
- The cord or band creates a flexion contracture at the finger joints as it crosses the joints; or, in other words, the cord pulls the finger into a bent position.
- Once the contracture has started, the process may proceed (either slowly or rapidly) to a severe deformity of one or several fingers.
- Even if only one or two fingers are involved, this condition may become so advanced that daily activities are awkward.
- Which fingers are affected most often?
- Ring finger
- Small finger
- Middle finger
- The index finger is seldom involved.
- Conservative treatment:
- Traditionally, I was not enthusiastic about non-operative treatments....
- Of course, non-surgical treatments do have less recuperation time, less discomfort, and quicker resumptions of normal activity.
- However, because less invasive treatments do not actually remove the diseased tissue, deformities are usually not completely corrected.
- Moreover, recurrence rates are invariably much higher than with a more traditional surgery.
- The classic, non-surgical treatment was a needle aponeurotomy.
- A very fine hypodermic needle divides the cord in multiple locations, allowing the finger to be immediately extended.
- Typically, patients wear band-aids for about 24 hours and resume their normal activities within a few days, without the need for any formal post-operative splinting or therapy
- The newest option is a non-operative technique called a collagenase injection.
- This is relatively new, and I am excited about its possibilities. However, I have very little experience with this intervention.
- It is an office-based procedure where a mixture of enzymes is placed into the diseased tissue. The enzymes work by dissolving the fibrous cord causing the contracture. Once the enzyme has had time to weaken the cord, typically by the following day, the finger is manipulated so that the cord will rupture and the finger can be straightened.
- Typical side effects may include bruising, swelling, and soreness at the injection site. No formal therapy is required, although a hand-based splint is prescribed for night use. Most patients resume normal use of their hand within two weeks.
- Traditionally, I was not enthusiastic about non-operative treatments....
- The mainstay for the treatment of Dupuytren's Disease is surgery, called a sub-total palmar fasciectomy....
- The aim of surgery in Dupuytren’s contracture is to regain maximum hand function, rather than totally cure the disease. If there is no present deformity and no loss of hand function, surgery may be delayed until significant deformity has developed. Therefore, the small palmar nodule rarely requires surgery unless it is sufficiently tender as to interfere with activities.
- A progressive contracture is regarded as an indicator for surgery and is best demonstrated when the hand can no longer be placed flat on a table top (Hueston's table top test). At this stage, there is sufficient deformity to demonstrate that hand function will eventually be threatened.
- A flexion deformity at the first finger joint (MCP) is usually correctable with surgery. A deformity at the second finger joint (PIP) is not always fully correctable, and sometimes can reoccur.
- Sub-total palmar fasciectomy is the surgical removal of the taut, retracted palmar fascia from the palm and afflicted finger(s). The amount of time spent during the operation depends on the amount of involvement, but surgery generally requires one to three hours. Surgery is usually performed under a general anesthetic.
- A zigzag incision is made in the palm of the hand and may be extended into the finger(s). Because it is extremely important to protect the nerves and blood vessels of the palm and fingers, meticulous dissection by the surgeon is necessary.
- Because of the type of incision, numerous stitches are required for adequate closure of the wound. Drains may be inserted to provide maximum drainage from the hand, and are usually removed the first or second day after surgery. On some occasions, I elect to leave part of the surgical wound open in order to prevent complications. In this instance, the incision heals naturally and stitches are not required.
- Following surgery, the hand is wrapped and immobilized in a large “boxing glove” type bulky compressive dressing, which is generally removed three to five days following surgery. The surgical wounds may be slow to heal and may occasionally gap open during the rehabilitation process. The physicians and therapists will monitor this closely in order to balance the program of wound care, exercise, and splinting.
Post-operative therapy appointments will be made for periodic checks on the healing progress. The hand therapist provides the patient with a specific exercise program. Discomfort with early therapy is not uncommon, but this improves with time. Several months of therapy may be required to regain joint mobility. Some residual inability to fully extend the involved fingers is common.
Skin incisions may remain large and somewhat tender for several months, but will gradually improve. Splinting the involved fingers to prevent the recurrence of contractures may be necessary (usually at night) for as long as 6-9 months following surgery. The goal of surgery is to remove the diseased tissue and to prevent additional contractures. Full return of finger function is not always possible and, in some cases, the deformity may reoccur.