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Dupuytren's contracture

Baron Dupuytren put his name to this condition in the early part of the 19th century, but it had been recorded long before that. The condition most often starts with a firm knot (nodule) in the skin of the palm. This may stay the same for months or years, or it may progress to the next stage in which cords of fibrous tissue form in the palm and may run into the fingers or thumb, pulling them into a flexed position.
In some patients the finger contracture develops without the condition in the palm. The initial  nodule can be painful, but later there is usually no pain. However, the contractures may seriously interfere with function. There is great variation in
the rate of progress, but it is usually possible to distinguish
the more aggressive form of the disease early on.
The fingers furthest from the thumb are most frequently affected, but any part of the hand and even the wrist area can be. Sometimes the cords develop from palm to finger, sometimes across the joints within the fingers, and sometimes both, when it produces the most troublesome contracture. In severe cases it can affect other parts of the body, most often the feet, but this produces an uncomfortable lump on the sole instead of toe contractures.

The cause of Dupuytren’s contracture is not fully understood. There is a genetic predisposition, which has been identified, so there may be a family history, and in some cases it appears to come to the patient’s attention after an injury or operation, but it is debatable whether these can be regarded as a sole cause. It may be that such incidents determine the time of onset of a contracture that was going to occur
anyway. Patients with certain other conditions have been
found to be more likely to develop Dupuytren’s contracture,
but this does not mean that they cause it, nor that people
with Dupuytren’s are likely to develop other illnesses. The conditions where there has been found to be an association include diabetes, epilepsy (possible due to the drugs that
are used), and liver disease, possible associated with high alcohol intake. Some people have heard of this association and worry that Dupuytren’s will be taken as an indicator of high alcohol intake, but there is no truth in this.

The abnormal tissue develops in the sheet of naturally occurring fibrous tissue that lies beneath the skin of the palm, with extensions into the fingers and thumb. This is called the “palmar fascia”, and has the function of stabilizing the skin of the palm during grasping and gripping, so that it does not slide around like the skin on the back of the hand. Fibres of palmar fascia run in all directions, but the fibres that form cords are longitudinal, and as they have the capacity to shorten, they pull the affected finger(s) into a flexed position. It is important to appreciate that the abnormal tissue does not involve the tendons that bend the fingers, and they can function normally once the contracting bands are removed as long as the joints are still mobile.

Treatment of the early “nodule” phase (without contraction) has not proved very helpful. Some have used steroid injections into the nodule, but without any dramatic effect. Once a contracture has developed to an extent that interferes with function, surgical excision of the contracted bands is generally felt to be the most appropriate treatment. In some patients there may be a case for less invasive methods. Needle fasciotomy has gained some popularity because of its simplicity and the lack of a wound to heal, with rapid recovery. However it is important to appreciate its limitations. The technique involves nicking one or more tight cords of Dupuytren’s tissue with a needle passed through the skin of the palm. This only works if there is an isolated cord without deep attachments, and this can be identified because the suitable cord lifts up the skin when placed under tension. When such a cord is released, the ends spring apart, and with the correct approach the skin remains intact. Rarely it can be helpful to treat a cord entering the finger in the same way, but the risk of nerve damage is introduced, limiting the indications for this. Needle fasciotomy in the palm is most often indicated in the elderly, but can buy some time for younger patients with appropriate distribution of the disease. A few days splintage is advisable to discourage early recurrent contracture.

Open surgical treatment is known as fasciectomy. This can usually be done under local anaesthetic (axillary block), with the patient awake, as a day case. Incisions are designed according to the position of the bands, but usually take a zig-zag line to avoid straight scars running longitudinally.The abnormal tissue is removed taking care to avoid damage to nerves and arteries running into the fingers. This can be very difficult especially when there has been a previous operation, but every effort is made to protect them. Division of a nerve results in loss of feeling on one side of a digit.

It is not always possible to restore full straightening to finger joints, even when all abnormal tissue is removed, because of tight ligaments which cannot always be released. Part of the incision may be deliberately left open in a crease in the palm; this allows freer movement and avoids collection of blood under the skin of the palm. It heals as well as if it had been stitched. After operation the hand is rested in a splint and bandage, and elevation in a sling at all times reduces swelling. The healing wound does require regular dressing changes in the two weeks after operation. Within this time a smaller splint is fitted and the hand mobilized. The splint should be worn at night for up to six months.

Most patients regain movement without too much difficulty, although determination and persistence are needed. Once the wound is healed, physiotherapy may be required once a week for up to two months, or sometimes more. A small proportion of patients have difficulty moving, and can have a stiff hand for some weeks or rarely longer. This is not possible to predict. A few patients develop a condition called 'Dystrophy' (see under Complex Regional Pain Syndrome), with sweating, stiffness or sensitivity to cold. When this occurs extended treatment including drugs and physiotherapy may be required.

Dupuytren’s contracture is not a fully curable condition. Eventually recurrence is likely in some form, elsewhere in the hand on in the same area, but the correct approach is to maintain function and mobility as far as possible, accepting that further surgery may eventually be necessary.

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