Dupuytren's disease and contracture
What is it?
Dupuytren's disease is a common benign condition that mostly affects people of northern European and Scandinavian descent. The disease is characterised by thickening of the palmar fascia, a specialised and intricate network of fibres in the palm of hand that sits just beneath the skin.
What are the symptoms?
When diseased, these fibres form palpable nodules and cords in the palm, which can extend into the fingers, thereby causing an inability to straighten the finger joints. This is known as a contracture - hence "Dupuytren's contracture".
In many people the manifestation of the disease is simply a few nodules in the palm, with no associated finger contractures - these patients do not require active treatment. In others, particularly male patients with a family history of the condition who manifest the disease at a younger age, the disease can follow an altogether more aggressive course.
What is the Treatment?
Intervention is generally advocated when the patient develops contractures of the finger joints of greater than 30 degrees. This is particularly so for the proximal interphalangeal (PIP) joints, which do not tolerate contractures well and can be more difficult to correct. Contractures of the metacarpophalangeal (MCP) joints are fortunately easier to remedy.
There are a few different options that are available for the treatment of Dupuytren's contracture:
- The traditional surgical option for Dupuytren's disease is known as a fasciectomy. The aim is to remove that part of the palmar fascia in the palm and finger(s) that is causing the contracture, while through careful dissection avoiding damage to the two digital nerves and arteries. This is not a curative operation, in that there is a documented recurrence rate. Nevertheless, it is still probably the "gold standard" and most widely used treatment, especially for PIP joint contractures. A plaster of paris cast is applied at the end of the surgery, and is kept in place until the patient sees a hand therapist a few days later. Hand therapy will be carried out to regain finger motion, to control swelling, and to maintain the correction by wearing a splint on the hand at night. It can take up to two months to regain finger motion and for the hand to recover from the surgery.
- In specific cases (recurrent disease, aggressive disease in younger patients) there may be an indication for a dermofasciectomy, which combines the removal of the diseased fascia with removal of part of the overlying skin of the finger, which is then replaced with a skin graft taken from the forearm.
- Needle fasciotomy
- This technique is particularly useful in patients who have a contracture of the MCP joint only. Such contractures are caused by a prominent cord of tissue that arises in the palm and extends to the base of the finger. This cord of tissue can be divided using a small hypodermic needle, and the finger then straightened. None of the diseased tissue is removed, however. The main advantages of this technique include the small wound and minimal amount of post-operative swelling. In addition, it is performed using local anaesthetic, so is useful for older patients who might not tolerate anaesthesia so well. There is probably a higher risk of recurrence of the contracture when compared to a fasciectomy.
- Collagenase injection (Xiapex)
- This is a relatively new treatment that is carried out in an outpatient setting, and involves the injection of an enzyme, collagenase, into the thickened cord of tissue causing the contracture. The cord is weakened by the injection. The patient is then seen 24 to 48 hours later, at which point it is usually possible to manipulate the finger into a straighter position. It can be used for fingers with both PIP and MCP joint involvement, but again seems most well suited to the correction of MCP joint contractures.
Mr. Gidwani will be able to explain the potential advantages and disadvantages of each of these techniques during your first consultation.