Dupuytren’s Disease / Contracture
This condition presents as a lump (nodule) in the palm of your hand which becomes larger and resembles a cord over time. The lump is often painless but occasionally may become tender and cause a degree of discomfort, which normally resolves over some months, despite the nodule or cord remaining present. The nodule or cord may subsequently go on to affect one or more fingers, causing them to bend up (contracture). When mild the contracture usually causes no functional problems in using your hand, but if the contractures become more severe, hand function is compromised.
Who gets Dupuytren’s?
This condition can occur in almost any adult, but due to its genetic origin, is more common in people of northern European decent. Dupuytren’s disease is more common in patients with some diseases including diabetes, liver disease, smokers and individuals taking anti-epileptic medications.
What causes Dupuytren’s?
The skin of the palm of your hand is different to that of most areas of your body, as it requires firm anchoring to the deeper structures to allow for the grasping of objects. To enable this anchoring to be present, a network of thick fibrous structures called the palmar fascia is present, connecting the skin to the bones in your hand. In Dupuytren’s disease, the palmar fascia becomes thickened and contracts causing the abnormalities mentioned above. Research is underway to look at the mechanism of Dupuytren’s disease in the cells of the hand. Although the mechanisms are becoming clearer, treatments to prevent this condition or reverse it without injection or surgery are still a long time away.
Dupuytren’s Treatment Options
Dupuytren’s disease is not infectious or cancerous, and there is no cure for the condition as it is a genetic condition. Nevertheless, it is possible to influence what happens within your palm with regards to the disease. Patients are not compelled to seek treatment for this condition, but opting for treatment may help straighten your finger(s). If you have a mild case, especially if it is not progressive, you are probably best advised to avoid initial treatment. Should the contracture become more significant, collagenase injection, or surgery and expert rehabilitation are usually the best options. If you can place your hand flat on a tabletop and your palm touches the table, then usually treatment is not worth your while, but once your palm no longer touches the table it is worth speaking to Mr Jarrett about treatment options.
There are three main treatment options: percutaneous needle fasciotomy, collagenase injection and fasciectomy surgery.
Percutaneous needle fasciotomy (PNF)
If you have ever had a blood test, you will realise that the needle must have a sharp tip to puncture your skin. If you look closely at the needle tip, it is in many ways like a tiny knife, and therefore a needle can be used via small holes in the skin of your palm to divide the fibrous cord causing the contracture thereby causing your finger to straighten. It is similar to a tight piece of string under the skin in your palm causing the finger to be bent, and the needle is being used to snip the string to allow the finger to straighten without actually removing the string. The advantage of PNF is it is a small treatment undertaken as a day case under local anaesthetic with most patients returning to work the next day and requiring dressings on their hand for no more than 1 to 2 days (just like when you have a blood test you do not need a dressing for much time at all). The disadvantage of PNF is some contractures are harder to treat with it and if the contracture is severe PNF will not get your finger as straight as other treatments. As with all treatments for Dupuytren’s Contracture, there is a risk of the contracture returning over time, although PNF or other treatments may be repeated in the future.
A relatively new form of treatment for Dupuytren’s Contracture is an injection of a medication called collagenase which contains an enzyme that dissolves the fibrous tissue causing the cord. This injection causes a degree of swelling and bruising of the hand. For approximately one to five days following the injection of the collagenase (tradename of XIAFLEX), the injected finger(s) are manipulated in the rooms with an injection of local anaesthetic. The collagenase injection has a significantly quicker recovery time compared to open surgery with less risk and produces nearly as good a contracture for almost as long a period.
There are risks of tendon or ligament rupture (very rare), and 1 in 8 patients have a small skin tear during manipulation which is treated by dressings for a few days. A splint usually worn at night for approximately a month and exercises are undertaken some several weeks after collagenase treatment. Some people may feel the lymph nodes in their armpit are slightly enlarged for some days, while others may feel like they have a cold for a day or two after the injection.
This procedure involves making some incisions in your hand and removing areas of the thickened fascia within the palm or finger(s) to allow the firm fibrous areas to be removed from your hand and your finger(s) to straighten. In some patients with severe contractures or contracture in several fingers, surgery may be the best option. If you want the maximum chance of improvement in contracture for the longest period possible, then surgery may also be the best choice for you. Surgery is most often carried out under an arm block, or general anaesthetic. A tourniquet is used to reduce bleeding, and the wounds are dressed by a moderately large bandage or plaster splint following the procedure. The risks of surgery include infection (1 to 2%), stiffness, bruising, nerve injury numbness on the finger (under 1%), and blood vessel injury (rare). Also, recurrence of the Dupuytren’s contracture is likely over time.
The treatment that would be best for you depends on the extent of your disease, your needs and your health. It is worth discussing your case with Mr Jarrett in his rooms to work out what is best for you. Early intervention is the most sensible approach before the contracture is too marked, or if it becomes apparent that progression to a level of impaired function is likely. This way, treatment is more likely to achieve the best results possible with less recovery time, less requirement for too complex a rehabilitation regime and fewer complications.
We surveyed our patients about the length of time they were unable to work following their treatments and for PNF and collagenase most patients returned to work the day following treatment. For surgery, the average length of time was 16 days.
Fasciectomy Surgery Postoperative Care
The hand must be elevated to prevent swelling for several days following the procedure. Hand therapy is commenced within a small number of days after surgery unless a skin graft is used, in which case hand therapy is delayed for a week. Absorbable sutures are used which do not require removal. A splint may be required at night time for several months following the operation, and extensive exercises under the control of our specialist hand therapists are required, both to maintain the correction of the contracture and to regain optimal hand function. The recovery time, rehabilitation time and intensity will be governed by the preoperative degree of contracture, and the magnitude of surgery undertaken.