Dupuytren's contracture

Dupuytren's contracture, or dupuytren's disease, is a condition affecting the hand, where fingers become bent towards the palm and cannot be straightened. Dupuytren's contracture is caused by a thickening of tissue within the palm which pulls the fingers back towards the palm.

Dupuytren's contracture can be treated through a surgical procedure which removes scar tissue beneath the skin of the fingers and the palm of the hand to help straighten the fingers.

Dupuytren's disease is a benign condition which affects the hands and, less commonly, the soles of the feet. It is believed to be inherited and is most prevalent in those with a Celtic genetic line. Dupuytren's disease is very variable - some will have a hard nodule in the palm which remains unchanged for many years while others, with a stronger genetic predisposition, will develop contracture of several fingers which progresses rapidly.

Many forms of dupuytren's contracture treatment have been proposed but few have become accepted or have stood the rigour of investigation and trials of their effectiveness.

In general, nodules which develop in the palm and which do not cause the fingers to bend, may be tender or painful in the early stages but this settles and the nodules require no treatment.

No treatment can cure the condition or the predisposition to develop dupuytren's contracture. All treatment is aimed at restoring range of movement and it is logical to reserve it only for those whose movement range is limited. Treatment is indicated, therefore, when the hand cannot be placed flat on a surface - the Table Top Test.

Less invasive dupuytren's contracture treatments include:

Needle fasciotomy

A needle is inserted under the skin and the sharp bevel of the tip is used to divide the cord which is pulling down the finger. This can be very effective in selected cases and requires little or no aftercare, but the recurrence rate is high since no tissue is removed and eventually the cord rejoins and once again contracts the digit.

Injection with collagenase

This is a relatively new treatment for dupuytren's contracture which achieves, by chemical means, the same outcome as a needle fasciotomy, but with a lower rate of recurrence. Collagenase is injected into the cord and is left for 24 hours after which the finger can then be straightened (by the surgeon) and range is restored. Once again, little or no tissue is removed and the cord is simply interrupted, so recurrence of contracture is likely, but at a lesser rate than needle fasciotomy.

Both needle fasciotomy and collagenase injection need careful selection since not all cases will be suitable. Those most suitable have a discrete cord, rather than a patch, of hard contracture.

Open surgery

This aims to open the skin of the palm and remove all abnormal tissue which is limiting the range of the fingers. Clearly this is the more invasive procedure after which intensive and expert hand therapy is required, but it offers the best chance of a disease and contracture free interval. Most hand surgeons will leave part of the palm wound open after surgery. This allows freer movement and avoids painful collection of blood beneath the palm skin.

Dupuytren's contracture surgery is usually performed under regional anaesthesia with the patient awake unless the procedure is expected to be prolonged, in which case general anaesthesia is preferred. Most, however, will be able to go home the same day, with the hand in a lightweight cast and the arm elevated in a sling.

Physiotherapy starts within a few days of surgery and is generally required for a few weeks. This physiotherapy is essential and is as important as the surgery.

A customised plastic splint is made by the therapist and is usually worn at night for several months.

Healing of the palm proceeds reliably over three to four weeks in most cases, but recovery will take weeks or months. During this time the hand will slowly be restored to suppleness and the scars will soften and become less tender. Determined use of the hand, moisturising and massage accelerates this process.

Recurrence of dupuytren's contracture in the digits which have been operated depends on the thoroughness of the surgery and on the individual's particular condition. New contractures in digits which have received no surgery are beyond the control of the surgery and are independent of the form of initial treatment - it depends on how aggressive or weak is the genetic predisposition to develop dupuytren's contracture in that specific individual.

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