Dupuytren’s Contracture is a hand deformity that usually develops slowly, over decades. It affects the connective tissue under the skin of your palm. It typically starts on the palm of the hand with a small nodule, or several nodules, that can be felt and are initially not very hard. The knots of tissue eventually form a thick cord that can pull one or more of your fingers into a bent position.
Once this occurs, the fingers affected by Dupuytren’s disease cannot be straightened completely, which can affect everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands. It most commonly affects the ring and little fingers.
What are the Classic Features of Dupuytren’s Contracture?
The ring and little fingers are most commonly affected, but any or all fingers can be involved. As the bend in the finger increases, it may be hard to straighten your finger. Grasping large objects and putting your hand in your pocket becomes difficult.
The skin on the palm of your hand may appear puckered or dimpled. A firm lump of tissue may form on your palm. This lump may be sensitive to the touch but usually isn’t painful.
What are the Causes of a Dupuytren’s Contracture?
Baron Guillaume Dupuytren first presented his findings on this disease in 1831, but the root causes of Dupuytren’s disease still remain unknown. The exact trigger that causes the palmar fascia to thicken and contract is unknown. However, contributing factors may include:
- Age – the condition is more common in middle to later years of life.
- Gender – 10 times more men than women are affected.
- Heredity – the condition tends to run in families.
- Ancestry – those with Celtic or Scandinavian ancestry are at increased risk. This is a major factor
- Certain medical conditions – people with diabetes have a higher risk, and also a greater risk of infection after surgery.
Treatment includes surgical and non-surgical options and depends on the severity of the condition.
In its earlier stages, reassurance is best, as not all Dupuytren’s progress at the same rate. In severe or advanced cases, the person is unable to lay their hand palm-down on a flat surface, or their fingers have contracted into their palm so that the hand has functional issues. At this stage, surgery is the best option.
At Glenelg Orthopaedics, we tend to undertake surgery when the condition becomes a hindrance. This usually involves when the knuckles (or MCP) joints are contracted at least 25º or there is equivalent contracture of the finger knuckles (PIP joints). This is when patients complain of difficulty putting the hand into the trouser pocket, or the finger gets in the way when washing the face.
Surgery is not undertaken for pain felt over the nodules because it can lead to painful scars. It is only undertaken when there is a significant hindrance to the patient because there is a rare risk of rapid recurrence. This is called a flare reaction, and occurs very rarely. However, we believe the patient needs to be certain that the problem is significant so that in the case of a flare reaction, they feel that it has been worthwhile at least attempting the surgery.
Surgery involves an operation under a general anaesthetic.
What are the risks?
Risks of the surgery need to be taken into account, the most important one being the risk of infection. In severe cases this may lead to readmission to hospital, use of antibiotics and regular dressings. If an infection develops, the wound is left open and will take several weeks to heal. The main problem of infection is the risk of scarring leading to a recurrence of a contracture.
A rare complication is the risk of nerve damage. The Dupuytren’s tissue surrounds the nerves, leading to it being entwined in the lesion itself. The operation involves careful dissection out of these nerves to protect them. However, there is a risk of a nerve being injured. Should this happen, it can be repaired but may not fully recover. In this scenario there may be some loss of sensation over the part of the finger, but would not affect movement of the finger.
Finally, there is a risk of recurrence, and this relates to the genetic causative factor. This may require further surgery if it develops as severe.
The surgery involves a general anaesthetic and a tourniquet. The incision zigzags into the palm and fingers. The nerves are carefully dissected and the Dupuytren’s tissue is released. Sometimes, the capsule along the knuckle closest to the base of the finger called the PIP joint needs to be released. A plaster is applied and worn for 8-10 days, after which we check the wound, remove the sutures, get the finger moving and use a night splint for the following four to six weeks.
The risk of infection is reduced by ceasing smoking before and for the weeks after the surgery and if there is any concern we advise the patient to contact us.
After surgery, hand therapy is needed to speed recovery and reduce the risks of the contracture returning.
Techniques may include:
- Splints worn at night for a few months to straighten the finger
- Sometimes, a splint worn during the day is needed as well
- Special hand exercises to encourage flexibility
- Gentle massage with moisturising handcream.