What is Dupuytren Contracture?
This is a benign condition characterised by firm nodules that appear in the palm and/or digits. This tends to affect the ring and little finger most commonly and is generally progressive, causing the fingers to lose range and bend into the palm. It is essential to appreciate that the condition varies from individual to individual. In some, the nodule in the palm remains static for many years and the contracture is minor. In others, the spread is rapid and the fingers contract in to the palm early in the progression.
What is the cause of Dupuytren Contracture?
The cause is not fully understood. It is more common in men than women and tends to appear in middle or late age. It is more common in Northern Europe and there is fairly accepted evidence that it originated in Scandinavian nations. It is relatively certain that there is a strong genetic link and DNA characteristics have been identified which are handed on, variably, sometimes with milder, sometimes more severe manifestations in offspring and relatives. The age of presentation also varies with more aggressive contracture developing in the young in some cases, and tends to progress faster.
A number of other conditions have been found to be associated, in the sense that Dupuytren contracture is more common in those with these conditions, but it is by no means certain that these other conditions cause Dupuytren contracture to develop. Occasionally it will appear sooner in a hand that has had trauma (such as a fracture) or surgery.
The contracting structure is scar-like tissue which forms beneath the skin. The tendons are not involved.
What are the Symptoms of Dupuytren Contracture?
Symptoms of Dupuytren Contracture may include:
- In the initial stages, the nodule is painful and this almost invariably settles with time
- The nodule may remain static for many years, but in many cases will develop cords into the fingers
- In more advanced stages, the cord limits straightening of the finger so that it becomes impossible to lay the hand flat, palm-down, on a surface.
- Contracture and limitation of range is slow and occurs over months.
- It is important to seek a specialist opinion when one is unable to lay the hand flat on a surface since a joint that is unable to straighten long-term. May develop a fixed contracture which is difficult to correct even after the nodule and cord are removed.
- Occasionally the first webspace between thumb and index finger is involved and one is unable to spread the thumb away from the hand.
What treatment is available?
The presence of nodules and cords is not an indication for surgery unless the range of movement of the fingers is limited. The test is the ‘Table Top’ test – an inability to lay the hand flat, palm-down, on a flat surface.
Once the range is limited, treatment is often indicated and a number of options are available. Selection depends on the precise distribution of the contracture, the specific joints involved and the expertise and experience of the surgeon.
No treatment will guarantee a cure and freedom from recurrence, either in the treated finger or in other digits. The likelihood of recurrence does depend on the selected method of treatment. Methods of treatment may include:
- Needle fasciotomy: In the procedure a needle is inserted beneath the skin and the cord, with a small amount of local anaesthetic. Using the bevel edge of the needle the fibres of the cord can be progressively divided such that this ‘gives’ and there is extension of the finger. No tissue is removed and the contracture invariably recurs after a period of some months.
- Chemical fasciotomy (Collagenase, marketed as Xiapex™): The same interruption of the cord can be achieved by injection of a chemical which dissolves collagen. Once again, no tissue is removed and the contracture recurs after a period of months.
- Open Surgery:
- Segmental fasciectomy: Short sections of cord are removed to interrupt the continuity and restore range. Once again, minimal tissue of removed and the contracture tends to recur after a variable period.
- Regional Fasciectomy: The entire cord is dissected and removed, restoring range. This is a more invasive operation which, of performed thoroughly (removing all abnormal tissue, holds out an improved chance of a contracture-free interval.
- Dermofasciectomy: This involves a radical removal of all diseased tissue and the overlying skin. It is generally reserved for those with repeated recurrence or who clearly have a genetic predilection to aggressive contracture at a young age.
The more invasive the method chosen, the more specialised and protracted is the post operative rehabilitation. A splint is generally recommended after surgery and a programme of hand therapy will minimise the chance of scar contracture replacing the Dupuytren’s contracture. Complications include: Recurrence, Stiffness, altered sensation, delayed healing.
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