Hand & Wrist Conditions
What is Dupuytren's Contracture?
Dupuytren's contracture is a common condition which affects the hands and fingers. It is seen mainly in the middle aged and elderly. Firm lumps and cords appear under the skin of the palm and can cause one or more fingers to bend into the palm. It can affect one or both hands. The thumb is less commonly involved. Sometimes lumps over the knuckles can be seen.
Why does it occur?
No one knows for certain but there appears to be a hereditary link. It is more common in those with Northern European heritage and runs in families. It is more common in men than women. There is also some association with diabetes, smoking, high alcohol intake, TB, and medication for epilepsy. Most people with Dupuytren's contracture however, are otherwise healthy.
Does it only affect the hands?
It mostly affects the hands, but in a few people there can be involvement of the soles of the feet or involvement of the tissues of the penis resulting in an abnormal curvature.
Is it harmful?
No. It is a benign (non-cancerous) condition. When advanced however it can significantly affect function in the affected hand.
What are the symptoms?
The first sign of Dupuytren's contracture is the appearance of a lump or nodule in the palm of the hand. Sometimes there is more than one and there may be pitting of the skin. These nodules can become painful. As the disease progresses, the nodules can progress to form bands or "cords" that extend into the fingers. The cords can contract resulting in bending of the fingers. The affected fingers are pulled towards the palm and the patient is unable to straighten them. The bending or "flexion contracture" can progress and cause difficulty with activities such as washing the face, putting the hands into pockets, shaking hands and wearing gloves. It is difficult to predict the rate of progression. Some patients only develop minor nodules in the palm whereas others develop severe flexion contractures.
How is it diagnosed?
Usually it is easy to diagnose from the history and the clinical examination. No further investigations are routinely ordered. If there is any doubt about the diagnosis, rarely an ultrasound scan may be requested.
How is Dupuytren's contracture treated?
This depends upon the severity of the condition.
In early cases of Dupuytren's contracture, treatment is not required.
When the disease starts to progress, then treatment is often required. However it should be noted that there is no cure for this condition. Treatment can make the finger straighter but does not eliminate the disease.
Early cases can be treated non- surgically using injection of an enzyme called collagenase (trade name Xiapex). This is a relatively new treatment for Dupuytren's contracture. It has not yet been approved for general use in the NHS by the National Institute for Health and Clinical Excellence (NICE). At present it has been accepted for use in certain areas.
Other relatively early cases can be treated by the latest technique of needle release. This is done in selected patients and can performed in the out-patient clinic or theatre under local anaesthetic. It is also known as Needle Aponeurotomy (NA) and Percutaneous Needle Fasciotomy (PNF).
What about surgery?
When the condition is more advanced in the palm or the fingers are significantly involved, then surgery is often required. This will involve excision of the band of the diseased tissue. This is a delicate and often prolonged operation, which requires hospital admission but is undertaken as a day case. The operation is routinely performed under a general anaesthetic. The aim of the operation is make the finger straighter and thus improve hand function. In advanced cases, the involved fingers may not fully straighten despite surgery.
What is the aftercare?
A bulky bandage is applied after the operation. A follow up appointment is given to see the surgeon, three to five days post-operatively. At this time the dressing will be reduced and the wounds inspected. Also night splints will be made by the hand therapist if required.
The patient will be seen by the hand therapist in the physiotherapist department within 5 days of the operation and will commence mobilization of the fingers at this stage.
Dissolvable sutures are usually utilised so removal is unnecessary. Patients will be followed up again in the clinic at about two weeks.
The night splint will be worn for at least 3 months post-operatively.
Are there any risks of surgery?
It is a low risk procedure, but like any operation has a few risks. Studies have found the overall complication rate to be around 5%. Some possible complications are:
- Damage to the nerves supplying sensation to the fingertips – if this should occur, the nerves are repaired and usually there is some recovery, but it is unlikely the fingers will recover their full sensation.
- Finger joint stiffness – the risk can be minimized by hand therapy.
- Delayed wound healing. (more likely to occur in smokers)
- Wound infection – this will usually be treated with antibiotics.
- Scar hypersensitivity and thickening.
- Haematoma – a collection of blood under the skin that forms as the wound heals, usually in the palm; it can be drained to reduce the swelling.
- Complex regional pain syndrome – a rare complication that causes the hand to become painful, stiff and swollen after surgery; it usually resolves itself within a few months, although sometimes it can be permanent.
- Blood vessel damage resulting in possible finger loss (although this is very unlikely)
- Recurrence of the condition