Dupuytren’s Contracture

Dupuytren’s contracture is a condition that affects the hands and fingers. It causes one or more of the fingers (on one or both hands) to bend into the palm of the hand.

The exact cause is unknown but tends to run in families and may indicate you have Viking Ancestry!

 SymptomsThe main symptoms of Dupuytren’s contracture are small nodules (growths or lumps of tissue) on the palm of your hand:

  • unusual lumps or dimples on your palm,
  • changes / thickening in the skin on your palm
  • any soreness, or
  • you cannot straighten your fingers as much as you used to be able to.

Progression
Dupuytren’s contracture occurs when nodules (small growths, or lumps, of tissue) appear in the connective tissue of the palm, under the skin. As Dupuytren’s contracture progresses, your fingers may eventually be pulled into a permanently flexed (bent) position. This can make it difficult to perform simple activities, such as washing face, playing a guitar, or shaking someone’s hand. The ring finger is normally affected first, followed by the little finger, and then the middle finger. In around 45% of cases, both hands are affected. In rare cases, the condition can also affect the soles and toes of the feet.

Causes
No one really knows what causes Dupuytren’s contracture. The most common factor is genetics.

  • male – 7 to 10 times more in men
  • > 40 years of age – nearly 80% of people are above 40 yrs
  • white northern European ethnicity – rare in asian & afro-carribean

Other contributing factors

  • cirrhosis of liver
  • diabetes
  • epilepsy
  • heavy alcohol and smoking

Deformed joints
A good indicator is if you are unable to put the hand flat on a table top. (Table Test of Hueston)

Surgery
Surgery is currently the gold standard method of treatment for Dupuytren’s contracture. The type of surgery that you have will depend on the severity of your contractures. It can either be a:

Fasciotomy – where the connective tissue is cut to relieve tension with a blade or needle. It is suitable for patients who have bands in the palm only and if unfit / unsuitable for complicated surgery. It does have a higher recurrence rate

Fasciectomy – A  fasciectomy involves the removal of the thickened connective tissue. A fasciectomy will usually be carried out under general anaesthetic or regional anaesthetic (when local anaesthetic is injected into your nerves so that you cannot feel pain, but you remain conscious).

During the procedure, a zig zag cut will be made in your hand and the affected connective tissue will be removed.  Sometimes a segment of the wound is not stitched being left open to heal itself (open palm technique)

Dermofasciectomy – In some situations it is necessary to remove the overlying skin in the hand / palm. This will be from an area that is usually concealed by clothing, such as your upper arm, the front side of your elbow. The healthy skin will be grafted (reconnected) onto your hand.

Amputation  Very rare in unoperated cases but may be preferred in finger in which the bands have returned many times or where there has been vessel and nerve injury. It may also be done in the elderly with severe deformity where rehabilitation after corrective surgery may be difficult

Non-surgical options
Xiapex injection is done in clinic followed by a manipulation of the deformed finger. An injection of collagenase clostridium histolyticum into the nodules has shown some promise, but the results are still in early stages. Three year results show comparable outcome to surgery.

Complications:

Scar  You will have a scar on the palm & finger (inner arm if you have skin grafting). This area will be firm to touch 7 tender for 2 – 3 months. This can be helped by massaging the area with moisturizing cream once the wound has healed.

Infection  Can occur after any operation. This would be treated with antibiotics

Nerve Damage  The nerves running into the fingers can be damaged during the surgery and cause numbness in part of the finger. This complication is unusual in unoperated areas but becomes more common during repeat operations. If this occurs the nerve would be repaired immediately

Recurrence  Dupuytren’s contracture can return either at the sidte of surgery or elsewhere in the hand. After a needle fasciotomy, the recurrence rate can be as high as 50%. After a fasciectomy, this decreases to 35%, and for dermofascietomy, the recurrence rate can be as low as 8%.

Bleeding  Can cause a collection of blood under the stitches which can cause wound problems. Tell the surgeon I fyou are on anticoagulants or aspirin

CRPS / Stiffness  About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation. This problem cannot be predicted but will be watched for afterwards and treated with therapy.

Correction it is often not possible to fully straighten fingers which are very bent at the time of operation, particularly if the bend occurs in the middle joint (PIPJ)

Finger loss  This is extremely rare but can occur in fingers which have had many operations before and in patients who have diseases of blood vessels.

Therapy
After having hand surgery for Dupuytren’s contracture, you may need specialised hand therapy to improve the function of your hand.

Splinting
Your hand may be put in a splint. Initially, splinting may be recommended all day, before only being used at night, and then gradually not used at all. Splinting will usually involve your fingers being bandaged to a plastic strip while they are in the straightest position that you find comfortable.

When can I start driving again?
You can start driving as soon as you feel confident enough to control the car safely. This is usually after about three weeks, but it may be longer if you have had a skin graft.

When can I go back to work and sport?
This depends on your job and on the type of operation that you have had. Someone who does heavy manual work may not be able to return to work for six weeks after having a skin graft. An office worker may be able to return to light duties a few days after having a fasciotomy. The same advice applies to sport.


Further Information

If you have any further questions then please ask at your clinic appointments.


Prof. Bijayendra Singh
Consultant Orthopaedic Surgeon
Medway Foundation NHS Trust
Spire Alexandra Hospital  Walderslade
BMI Somerfield Hospital  Maidstone
Kent Institute of Medicine & Surgery  Maidstone

Visiting Professor, Canterbury Christchurch University.



Private Secretary: Anne Church
Email: annechurch@gmail.com
Phone: 07745 – 120785

Website:
www.finger2shouldersurgery.co.uk
www.kentorthopaedicpractice.co.uk


This information has been designed to help you gain the maximum benefit in the management of your condition. It is not intended to be a substitute for professional care and should be used in association with the recommendations given by your orthopaedic consultant. Individual variations needing specific instructions not mentioned here may be required.