Dupuytrens disease

What is Dupuytrens disease?

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Dupuytrens disease also know as "Dupuytrens contracture" is a common condition that can cause nodules or progressive bending (contractures) of the fingers. Although not normally painful, it can lead to reduced function of the hand by preventing the fingers from being able to be straightened fully. It is more common in males, particularly those of northern European descent and often begins in middle age.

What causes Dupuytrens disease?

The exact cause of Dupuytrens is not fully understood. It often runs in families suggesting a possible genetic link and there is an increased risk of the condition in diabetic patients, smokers and those who have a high alcohol intake.

Some patients start to develop the first signs of Dupuytrens after experiencing minor trauma, for example following a fall or after sustaining a broken bone in the wrist. It can also be seen following planned surgery to the hand. It does not appear that these injuries or surgeries cause the Dupuytrens, more that they activate a dormant process within the hand triggering the condition.

What are the signs and symptoms of Dupuytrens disease?

 

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The above image shows Dupuytrens disease and a contracture of the ring finger

Dupuytrens disease can lead to firm nodules in the palm or thickened cord like structures in the palm or fingers. Whilst these are not usually painful, they can be tender in the early stages of the condition.

Contractures occur when the fingers are forced into a bent position as a result of the development of these thickened cords and nodules. It is usually a slow process where there is a gradual deterioration in the position of the fingers over many months or years.

The most likely affected fingers are the little and ring fingers. The other digits are less commonly affected and suggest more aggressive disease.

The contractures affect the digit in the following three ways, in isolation or in combination with each other.

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MCPJ contracture

The metacarpal phalangeal joint (MCPJ) is the joint where the finger joins the hand. This is the most commonly affected joint in Dupuytrens and causes the finger to bend forwards.

This joint can be affected on its own or in combination with the other joints as listed below.

 

If this is affected in isolation then the outcomes of surgery are usually excellent and a full correction is usually expected.

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PIPJ contracture

The proximal interphalangeal joint (PIPJ) is the middle joint in the finger.

This joint can affected on its own or in combination with the other joints as listed above and below.

The outcomes of surgery when this joint is involved is more variable than with an isolated MCP joint contracture.  

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DIPJ contracture

The distal interphalangeal joint (DIPJ) is the last joint in the finger just below the nail.

 

 

This joint is less commonly involved and will often occur in conjunction with the other two joints above. The result is usually a more severe contracture.

What does Dupuytrens look like up close?

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Nodules - These are often the first sign of Dupuytrens and feel like small hard lumps in the palm or finger.

Pitting - Pits can form as the skin is tethered onto the underlying cord causing small depressions.

 

Cords

These represent the long rope like structures in the palm. They can be confused with tendons as they run in the same direction.

 

 

Associated conditions

Dupuytrens disease can present with other clinical signs in different parts of the body. Most individuals with Dupuytrens of the hand will not have these other features. However if one or more are present this can indicate a more severe form of the disease.

 

Feet

The same contractures or cords affecting the feet are known as Ledderhose disease. This condition is dealt with by a foot and ankle surgeon.

Penis

Thickened cords or contractures on the penis are known as Peyronie's disease and would be dealt with by a Urologist.

Knuckles

Thickened tissue on the back of the knuckles are known as Garrod's pads. They do not usually require any treatment.

Dupuytren's Diathesis

Dupuytren's diathesis is a term given to patients who present with slightly atypical symptoms and present with a more severe form of the condition.

We would describe patient's as being Diathesis if they present as follows;

  1. Younger age

  2. Bilateral involvement (both hands affected)

  3. Rapid deterioration

  4. Garrods Pads

  5. Peyronie's disease

  6. Ledderhose disease.

  7. Thumb index and middle finger involvement

  8. Aggressive recurrence (rapid recurrence after treatment)

Diagnosis

Dupuytren's disease is usually diagnosed by simply examining the hands and is often made within a few seconds of seeing the patient. The diagnosis can also be made by merely seeing a photograph as the features are so typical.

Very rarely a small unusual looking nodule may require further investigation by ultrasound to confirm the diagnosis. 

Treatment

Unfortunately and unusually for hand conditions there is a limited role for non-surgical treatments. The use of splints or therapies will not halt the progression of the condition.

Surgery is offered to individuals if the condition is affecting the quality of life of the individual or affecting their ability to work. Within the NHS treatment for this condition has been unfortunately rationed and surgery will only be offered to patients once they have a minimum degree of contracture.

The surgical options are on a spectrum of complexity,  recovery and recurrence and can be seen below.

Needle fasciotomy

This is the most simple procedure we offer. It has the quickest recovery, a low risk profile and acceptable recurrence rates.

This procedure is performed under local anaesthetic as a day case procedure.  It often only takes around 30 minutes to perform.

With this procedure a small amount of local anaesthetic is injected into the skin overlying the contracted cord. The tip of the needle is then used to divide the contracted cord without the need for any cuts in the skin.  Once the cord has been divided the finger should straighten. At the end of the procedure local anaesthetic will be further injected to numb the whole finger prior to it being stretched out. Small dressings are often applied for the first few days and the fingers are moved as soon as possible.

The risks include

- Infection

- Nerve injury (which could lead to some numbness in the finger).

- Damage to tendons

- Injury to the artery

- Skin tear (these are often very mild but if present, heal extremely well         but can slow the rehabilitation slightly).

- Stiffness

- Chronic pain.

The recurrence rate is around 55% at 5 years. This means that just over half of patients will notice a recurrence within the first five years after surgery. This does not mean however, that the contracture is back to the same level as it was preoperatively. It just means that some form of contracture has developed.

Needle fasciotomy is suited to individuals who do not want to take much time off work, for example manual workers, self employed individuals or those needing a quick return to function.  It is a minimally invasive procedure and low in risk. It is also possible to move to an open fasciectomy if recurrence occurs without any real difficulty.

Open fasciectomy

This is probably the most commonly performed procedure for Dupuytren's disease. It is often performed under either a regional anaesthetic (where the patient is awake but with a numbed arm) or under a general anaesthetic (where the patient is "asleep''). This will also be a day case procedure but as incisions are made in the skin the recovery is longer.

In this procedure incisions are made in the finger and palm and rather than just dividing the thickened cord, it is removed. Following this surgery the finger is bandaged and a plaster cast is normally applied holding the finger straight for the first week. After a week patients are seen by the hand therapy team where a splint is made for them to wear at night time for three months. This splint will stretch the finger out straight. 

The risks include;

- Scar and scar sensitivity

- Infection

- Nerve injury (which could lead to some numbness in the finger)

- Damage to tendons

- Artery injury

- Stiffness

- Chronic pain.

The recurrence rate are around 35-40% at 5 years but this does not mean that the contracture is back to the same level as it was preoperatively, it just means that there is some form of contracture present.

This procedure is more likely to improve the position of a PIPJ contracture particularly if it is severe. 

This procedure does create more scarring on the inside of the finger which means that if there is a recurrence, the risks associated with future surgery (e.g. nerve damage) increase as result.  

Dermofasciectomy

This procedure is identical to a open fasciectomy but in addition can remove skin overlying the Dupuytren cord and replace it with a skin graft. This skin graft is usually taken from the forearm. 

There is a lot of evidence to suggest that by performing a skin graft after performing the fasciectomy, the chances of having a recurrence of the condition are far lower. We therefore offer this procedure to patients with Dupuytren diathesis (see above) or to a finger that has already had multiple surgeries in the past.

We do not offer this procedure as standard as for most patients it is unnecessary, longer and with a greater risk of associated complications.

The risks of dermofasciectomy are the same as for the open  fasciectomy but there are the additional risks of failure of the skin graft and complications at the donor site (usually the forearm). There is also a longer recovery period than the two other procedures (above).

Recurrence rates are between 5 and 10% at 5 years.

Enzyme therapy

A novel treatment using enzyme therapy has been used for some years. This treatment is injected into the thickened cord and the enzyme breaks it down. A follow-up appointment is often made after 3 days and local anaesthetic is injected to numb the fingers and they are then stretched to complete the rupture of the cord.

Unfortunately the main distributor of the product, known as Xiapex, has withdrawn it from the European market (including the UK ) Since 2019 it has therefore not been available.

 
 
 
 
 
 
 
 
 
 

Recovery

The type of surgery you have will determine your rate of recovery.

Patients having needle fasciotomies will experience a rapid return to function. They can usually use the hand for most activities within a few days. It may be slightly tender to grip but it is safe to do so immediately. Driving is normally safe after a few days once the hand is comfortable and capable of gripping the steering wheel. Manual workers may take up to 2 weeks in order to feel comfortable using the hand for heavy tasks.

Open procedures (open fasciectomy and dermofasciectomy) have a longer recovery period. There is a greater amount of trauma to the finger which is likely to cause more swelling and stiffness. Generally the wounds take two weeks to heal and until this point the wound needs to be kept dry and usually covered with dressings. Gentle movement is encouraged early on but until the wounds are healed the movement needs to be limited. If a skin graft is needed the finger is often immobilised for a longer period to protect the graft until it has become integrated.

Return to function is variable. Most patients will be able to drive after around four weeks but some take longer. Manual workers may take six weeks or more before they feel comfortable using the hand for manual work.

Once the wounds have healed it is important to work hard to regain movement. The fingers do not tolerate being immobilised for long and must be moved early to prevent long term stiffness.

The wounds can continue to improve for up to a year and will become less red and soften up over time until usually all that can be seen is a thin white scar.

aboutus

Devon Hand Surgery aims to give you an early diagnosis, rapid treatment (which can often be non-surgical) and perform any necessary surgery when required. We will also supervise your rehabilitation to ensure you have the best chance of restoring function, getting back to work and improving your quality of life.