Dupuytren's Contracture

Historical

Baron Guillaume Dupuytren, a celebrated French surgeon, first described Dupuytren’s disease in 1831. He revealed that the cause was a taut, retracted and shortened palmar fascia producing a permanent retraction of the fingers. Thus the name of Dupuytren's Contracture became affixed to this malady.

Who gets it?

Dupuytren's Contracture is a common condition that affects approximately 1% of individuals of Caucasian descent. It generally appears in later life 40 to 60 years. It affects more males than females -about 8-1, and it has a strong familial tendency.

Cause

The exact cause of this process is unknown. It may be seen with other aging connective tissue diseases (bursitis, arthritis, tendonitis, etc.).

Generally, trauma is not felt to be a factor. All hands suffer varying degrees of trauma throughout life, and the apparent relationship to trauma in severe cases is probably coincidental.

Signs & Symptoms

The most common first evidence of the disease appears as a "lump" in the palm near the distal palmar crease at the base of ring and small fingers. It can also be at the base of the other digits and even the thumb.

Although the appearance of nodules in the finger usually occurs in the disease, they may be present as the first sign. 

The Pit

The pit may be single or multiple and appears as a small local deep indentation of the skin. It may be the first finding it may come later, or it may never appear. It is usually located in the palm but can also be in the fingers.

The pit occurs due to contraction of the connective tissue fibers from the palmar fascia to the skin the skin is drawn down to form the pit. 

The Cord

The cord is a longitudinal fibrous band, either multiple or single, which extends from the palm to the finger(s). It usually appears with a nodule, but it can be separate.

The cord creates a flexion contracture at the finger joints as it spans the joints. Once contracture has started, the process may proceed slowly or rapidly to a severe flexion deformity of one or several digits. Even if one or two fingers are involved, the condition may become so incapacitating that everyday activities are embarrassingly awkward.

The ring and small fingers are most frequently affected, the long finger next, followed by the thumb; the index finger is seldom involved.

Nature of Disease

• The disease usually progresses slowly. It may have periods of temporary arrest or rapid progression for varying lengths of time.
• Involvement of the feet may be associated in 15% -20% of cases.
• Bilateral (both hands) involvement is a near certainty,sooner or later.
• Most often begins in palm at base of ring or small fingers.
• Flexion contractures occur at either of the first two finger joints.
• The flexor tendons are never involved in this process.
• Skin may be involved by the infiltration of dermal layers.
• The process is not malignant.
• Not painful, except for possible tenderness in area of infiltration or during an inflammatory phase.
• A complete cure is usually impossible.
• Recurrence is frequent, particularly at the middle finger joints.

Treatment - Surgery

The aim of surgery in Dupuytren's Contracture is the retention of normal hand function rather than total cure of the disease. In the absence of deformity, there is no loss of hand function and surgery is delayed until significant progressive deformity has developed.

Therefore, the palmar nodule rarely requires surgery unless it is sufficiently tender to interfere with the patient's occupation.

A progressive contracture is regarded as an indication for surgery and is best demonstrated when the hand can no longer be placed flat on the table top. At this stage there is sufficient deformity to demonstrate that hand function will sooner or later be threatened.

Important Considerations

• A palmar node alone does not yet warrant surgery.
• MCP flexion deformity is almost always fully correctable by surgery.
• PIP joint deformity is not always correctable by surgery and has the highest tendency to recur.

The Operation

Subtotal palmar fasciectomy is the surgical removal of the taut, retracted palmar fascia from the palm and affected fingers(s). 

The amount of time spent on the operation depends on the amount of involvement, but generally it requires 1 ½ to 2 ½ hours. It is performed under general or regional anesthesia. A pneumatic tourniquet is always applied, and this allows the surgeon to perform the operation in a bloodless field. 

A zig-zag incision is made in the palm and extends into the finger(s). This allows for better healing of the skin and a gain in skin length to further aid in relieving the contracture. It is extremely important to protect the nerves and blood vessels of the palm and digits and meticulous dissection by the surgeon is carried out.

Because of the necessity of this type incision, numerous amounts of "stitches" are required for adequate closure of the wound. Drains are often inserted to provide maximum drainage from the hand and are removed usually the first or second day after surgery. On some occasions, the surgeon may even elect to have the surgical wound open in order to prevent impending complications.

Dressing:

Postoperative Care:

• Elevate the affected hand above your heart for the first 48 hours. You may sleep with your arm on a pillow placed across your chest.
• Flex and extend your free fingers as much as possible.
• You may experience some degree of pain following surgery, although this procedure is often relatively pain-free. We will provide pain medication should you require it.

Important Considerations:

• The surgical wounds will often be slow to heal and may occasionally open up somewhat. This results from the intimate relationship between the disease and the overlying skin and the need to thin the thick palmar skin in order to remove the contracted fascia.
• The finger exercises must be started soon after surgery and religiously carried out to avoid joint stiffness, which can be a complication of this surgery.
• It may require many months of exercises to regain joint mobility, and some residual inability to fully extend involved fingers is not unusual.
• Splinting of the involved finger to prevent the recurrence of contractures may be necessary (usually at night) for as long as six to nine months following surgery.
• Skin incisions may remain large and some- what tender for several months but will gradually improve.
• The surgery is meant to remove the diseased tissue and prevent additional contracture. Full return of finger function is not always possible and recurrence is possible.