Information for patients with Dupuytren's Disease.
Edited By: Thomas Trumble, M.D.
Last updated Wednesday, January 12, 2005
Figure 1 - The typical appearance of a hand affected by Dupuytrens contracture. Figure 3 - the appearance of hands after fasciectomy. Figure 4 - the appearance of hands after fasciectomy. Figure 2 - Examples of several different types of incisions used. AboutOverview Dupuytren's disease is a slowly progressive condition that causes
flexion contractures of the fingers and thumb. This means that the
affected fingers (most often the small and ring) get pulled down toward
the palm, and the ability to straighten the fingers is lost. Surgery is
the only widely accepted treatment for this condition. Dupuytren's
disease is not dangerous in terms of the patient's general health, but
can interfere with the patient's ability to use their hands for work or
recreation. In general, surgery is useful once hand function becomes
significantly compromised.
The nature of this condition, the role of surgery and other
interventions, potential complications and recovery after surgery will
be discussed below.
Characteristics of dupuytren's disease Dupuytren's disease, or Dupuytren's contracture is a condition of
the hands that causes both a loss of mobility and an abnormal position
of the fingers and/or thumb. Patients with Dupuytren's disease develop
abnormal lumps and "cords" of tissue in the palm and fingers. These
lumps and cords represent an abnormal growth of the palmar fascia — the
"gristle" like tissue normally present in the hand that holds the skin
of the palm in place.
As the Dupuytren's cords tighten over time, the joints of the
fingers are pulled into flexion, causing the fingers to be pulled down
into the palm, and impairing the ability to straighten the fingers. The
thumb may also be affected, though this is less common. The rate at
which symptoms progress is highly variable among patients. In many
patients the disease may be stable over a long period of time and
require observation only. In others, it may progress more rapidly and
require earlier surgical intervention.
Patients with a strong family history, and the presence of related
conditions such as Peyronie's disease (abnormal fascial growth in the
penis), Ledderhosen disease (a condition similar to Dupuytren's disease
affecting the soles of the feet) and knuckle pads (lumps of abnormal
tissue over the knuckles) are more likely to have more severe and rapid
progression. As the condition progresses, the flexion deformity can
worsen, and the patient can lose the ability to straighten out the
affected fingers. The lumps and cords can also be painful. Figure 1
shows the typical appearance of a hand affected by Dupuytrens
contracture. Types Dupuytren's disease has not been classified into specific subtypes.
There is, however, a wide variation in the degree to which patients may
be affected. This ranges from very mild contractures of a single digit,
to severe contractures of several digits. Early on in the disease
process, affected individuals may only have a small lump of abnormal
tissue in the palm (a Dupuytren's nodule). Some patient's are said to
have a strong "Dupuytren's diathesis". This refers to patients with a
strong family history and who may have associated conditions such as
Peyronie's disease, Ledderhosen disease and knuckle pads (described
above). In these patients, Dupuytren's disease is often more aggressive
in nature.Similar conditions There are few conditions that can be confused with Dupuytren's disease.
Other conditions that may cause in inability to fully straighten the
fingers include trigger finger (which occurs more commonly in patients
with Dupuytren's disease), extensor tendon rupture (due to injury or
arthritis), joint stiffness following injury and/or immobilization of
the hand in a splint or cast, joint stiffness due to arthritis, injury
to the ulnar nerve resulting in a ¡§claw hand¡¨ deformity, or
subluxation (slipping) of the extensor tendons between the knuckles in
patients with arthtritis. However, none of these conditions result in
the palmar nodules and cords seen in Dupuytren's disease, making the
clinical diagnosis of Dupuytren's disease relatively straight forward.
Confusion may occur when Dupuytren's disease and one or more of these
other conditions are present in the same patient.Incidence and risk factors Dupuytren's disease is most common in Caucasian males over 50 years
of age, though it also occurs in women and in younger patients. It has
also been shown to be more common in diabetics, patients with seizure
disorders, HIV positive patients, patients with hypothyroidism, and in
those who smoke and consume alcohol. Having blood relatives with the
disease also increases a person's chance of being affected, especially
in those with northern European ancestory. However, not all children of
an affected individual will develop the disease, and not all patients
with the disease will have an affected family member.
When several factors such as these are known to be linked to a
disease, but none can be shown to be directly responsible, the cause is
said to be "multifactorial". This means that there are several things
that can increase a chance that a person will be affected, but a single
cause is not known. Diagnosis Usually, affected patients notice an abnormal lump in their palm early
in the disease process and present to their family doctor. The
condition is usually recognized at this point prompting referral to a
hand surgeon who can assess and follow the patient with regard to the
need for surgical intervention. The diagnosis is based on the patients
symptoms and the physical exam. There are no special tests such as
x-rays, other imaging studies, or blood tests required to make the
diagnosis.Medications Currently there are no medications used to manage Dupuytren's
disease. However, clinical trials evaluating the effectiveness of
collagenase injections are underway. Collagenase is an enzyme that
breaks down collagen, the molecule that makes up the cords of
Dupuytren's tissue in the hand. Initial studies have suggested that the
majority of patients may derive benefit in terms of improved finger
motion when treated with collagenase instead of surgery. The results of
the current trials will shed more light on this new technique. It will
also be important to assess the results over time in order to determine
the rate of contracture recurrence.
Other non-surgical treatments that have been reported include
radiotherapy, ultrasound, preoperative splinting, topical and injected
steroids, dimethyl sulfoxide (DMSO), colchicine and gamma-interferon.
None of these have shown sufficient benefit or become established
treatment options for Dupuytren's disease. Exercises Exercises have not been found to be an effective treatment for the
contractures associated with Dupuytren's disease. However, some
surgeons may refer patients to a hand therapist for stretching of a
severely involved finger prior to surgery, though this is not common.Possible benefits of palmar fasciectomy In Dupuytren's disease, the flexion contractures that cause
disability are the result of an abnormal growth of the palmar fascia.
This abnormal fascia arranges itself as "cords" which tighten over
time, pulling the affected fingers into an abnormal position. Surgery
for Dupuytren's disease involves the removal, or excision, of this
abnormal tissue. By removing the abnormal fascia, the surgeon can often
restore motion to the affected fingers. Sometimes the finger cannot be
fully restored to normal, and some flexion contracture persists,
however, most patients experience an improvement in hand function after
surgery.
Types of surgery recommended Surgery is the mainstay of treatment for Dupuytren's disease.
Surgery is indicated once the patient and surgeon agree that the
condition is causing significant problems for the patient, and that
these problems are likely to be improved by surgery. Sometimes only the
most affected fingers will be operated on. If several fingers are
severely affected, then all of these may be operated on.
Surgery for Dupuytren's contracture is called "fasciectomy" because
it involves the removal of the abnormal palmar fascia that causes the
flexion deformity. The abnormal fascia is sometimes called "Dupuytren's
tissue". Surgery is usually done on an outpatient basis which means
that the patient will go home the same day of surgery. It can be done
with the patient asleep (general anesthetic) or awake with the arm
"frozen" (local or regional anesthetic). The decision as to which type
of anesthetic to use is usually made by the patient and their surgeon
or anesthetist. During the operation the surgeon makes incisions in the
palm and the affected fingers. Several different types of incisions can
be used (Figure 2). The surgeon removes the abnormal Dupuytren's tissue
in order to correct the flexion deformity and allow the finger to
extend. It is not always possible to achieve full correction, depending
on which joint is affected, the severity of the deformity, and the
amount of time that the deformity has been present. Figures 3 and 4
show the appearance of hands after fasciectomy.
Who should consider palmar fasciectomy? Initially, Dupuytren's disease is often observed for a period of
time. This is because it often does not significantly interfere with
hand function. The disease is not curable with surgical intervention
and often recurs after surgery (about 50% of the time). Therefore, it
is not preferable to undergo surgery unless the condition is causing a
significant problem with hand function or is causing persistent
discomfort. Some guidelines for when surgery is warranted include,
flexion contracture >30 degrees at the metacarpal phalangeal joint
(the first knuckle, closest to the wrist), progressive flexion
contracture at the proximal interphalangeal joint (the second knuckle),
and persistent pain. These guidelines are not followed rigidly, and
generally surgery is warranted when the patient and surgeon feel that
the condition is causing significant problems for the patient that are
likely to be improved by surgery.
What happens without surgery? Often it is preferable to postpone surgery if the condition is not
severe enough to interfere with the patients day to day activities. The
condition may remain stable for long periods, in which case no surgery
is needed. In other cases the disease progresses more rapidly. It is
difficult to predict how quickly the disease will progress in each
affected patient.Surgical options Several different operations have been described for Dupuytren's disease. The most widely accepted is called partial palmar fasciectomy,
in which the surgeon removes the abnormal Dpuytren's tissue from the
palm and the affected fingers. This can be done through a number of
different incisions depending on the surgeon's preference. At the end
of the operation all of the incisions may be sewn closed, or some may
be left open to allow drainage. Both are accepted methods.
Other approaches include: the removal of all of the fascia, whether it is involved or not (total palmar fasciectomy); simply cutting the Dupuytren's cords in the palm (palmar fasciotomy)
— a method associated with higher recurrence, but often useful in
patients severely debilitated by other conditions; collagenase
injections — an experimental approach described above that is currently
in clinical trials. Sometimes (though not commonly) skin is excised as
well, especially in very severe cases, and replaced by skin grafts
(thin pieces of skin taken from another area of the body and placed
onto the open areas of the palm).
Effectiveness Most patients have an improvement in hand function after surgery for
Dupuytren's disease. This is related to an improved ability to
straighten, or extend the fingers, and decreased flexion contracture.
The amount of benefit that a patient experiences is difficult to
predict preoperatively but is related to the severity of the
contracture being corrected and the joint involved. In general,
contractures of the proximal interphalangeal joint (PIP) are more
difficult to correct. Also, long standing contractures are more
difficult to correct. The improved motion experienced by the patient
usually persists for several years though approximately 50% of patients
will have some degree of recurrence over a 5-10 year period after
surgery.Urgency Surgery is not urgent and it is not dangerous to the patient's general
health to postpone surgery. In fact, surgery should not be undertaken
unless the contractures are causing significant impairment of the
patient's ability to perform activities related to work or recreation.
Occasionally surgery is undertaken to relieve the pain that is
sometimes associated with Dupuytren's nodules, or too facilitate
personal hygiene in debilitated patients with severe contactures.Risks There are potential complications with any operation. In surgery for
Dupuytrens disease these include: scarring, infection, hematoma (a
collection of blood under the skin), skin necrosis (loss of skin due to
poor blood supply), recurrence of disease, finger stiffness requiring
physiotherapy, and injury to nerves and vessels. Nerve injury can cause
finger numbness which is usually temporary but can be permanent. Vessel
injury due to the accidental cutting of a vessel or stretching of
vessels when the affected finger is straightened can cause loss of the
entire finger. This has been reported in the medical literature but is
rare.Managing risk If complications such as nerve or vessel injury occur during surgery,
and are recognized, they are repaired at that time. It is uncommon for
a nerve or vessel to be cut though this complication can occur. Vessels
can also be damaged by straightening the finger during surgery, causing
stretching of the vessels which have become shortened due to the
contracture. This can cause poor blood flow to the finger which usually
improves over several minutes of relaxing the finger and applying warm
sponges. When vessels are damaged the worst case scenario is loss of
the finger though this is very rare. Post operatively, if infection
occurs this is usually managed with antibiotics, either by mouth or
intravenously depending on the severity of the infection. Occasionally,
an infection may require return to the OR for drainage. If skin
necrosis occurs (death of an area of skin due to poor blood supply),
this is usually managed initially with observation and later removal of
the dead tissue. Often the resulting wound will heal in on its own with
dressing changes, or a skin graft may be required to achieve wound
closure. Hematoma (a collection of blood under the skin) is managed
with observation if the hematoma is small enough to absorb in a
reasonable amount of time. Larger hematomas require drainage to prevent
skin necrosis and infection. Recurrence of contracture is prevented
with physical therapy and splinting, though despite the best efforts
some degree of recurrence is fairly common.Preparation Usually patients are instructed not to eat or drink anything after
midnight prior to the day of surgery. This is to ensure that the
stomach is empty. If patients eat on the day of surgery and have a
general anesthetic, they risk vomiting and aspirating. This means that
vomit enters the lungs — a complication that can cause serious
infections and death.Timing Surgery can safely be delayed until the disease has progressed to the
point that it is interfering with the patients daily activities. At
this point, surgery is indicated if the surgeon feels that the patient
would benefit.Costs The surgeon's office should provide a reasonable estimate of:
- the surgeon's fee,
- the hospital fee, and the degree to which these should be covered by the patient's insurance.
Surgical team Surgery for Dupuytren's contracture should be performed by a surgeon
with additional training in hand surgery. Hand surgeons can be
orthopedic surgeons, plastic surgeons or general surgeons who have
received training in hand surgery.Finding an experienced surgeon Most hand surgeons are familiar with the diagnosis and treatment of
Dupuytren's disease. Hand surgeons are usually orthopedic surgeons,
plastic surgeons, or general surgeons with extra training in hand
surgery. In general, primary care providers can arrange a referral to a
qualified surgeon. The homepage of the American Society for Surgery of
the Hand (ASSH) provides contact information for qualified hand
surgeons (www.assh.org).Facilities Because patients can usually be discharged home on the day of surgery,
surgery for Dupuytren's disease can be performed in large hospitals or
smaller OR settings.Technical details Prior to surgery the surgeon will decide with the patient which fingers
will be operated on. At the time of surgery a tourniquet (similar to a
blood pressure cuff) is placed around the arm above the elbow. The arm
and hand are prepared with an antimicrobial solution to decrease the
risk of infection. After applying sterile drapes around the hand and
arm the tourniquet is inflated to control bleeding in the hand. Next,
the surgeon will make incisions in the palm and in the affected
fingers. The incisions are all on the palm side of the hand. Through
these incisions the surgeon identifies and exposes the abnormal fascia
(Dupuytren's tissue). During the dissection of the Dupuytren's tissue
the arteries and nerves going to the fingers are identified and
protected to prevent injury. All abnormal fascia is removed, allowing
improved motion of the affected finger. Sometimes it is necessary to
further release structures around affected joints in order to achieve
improved motion. The surgeon may make "Z" shaped incisions over areas
of skin tightness to allow lengthening of the skin, further improving
finger motion. Next, the tourniquet is deflated and bleeding
controlled. The incisions are closed (though some may be left open to
allow drainage) and a dressing and splint are applied.Anesthetic Surgery for Dupuytren's disease can be done with local or regional
anesthetics (techniques to "freeze" the hand or limb) or general
anesthesia ("going to sleep"). The decision as to what type of
anesthetic to use is made by the patient, anesthetist and surgeon and
depends on the anticipated length of the procedure and the patients
overall health.Length of palmar fasciectomy The length of the surgical procedure is directly related to the number
of fingers involved and the severity of involvement. For this reason
surgery can take anywhere from one to several hours.Pain and pain management Postoperative pain is usually manageable with oral (by mouth)
medications. Usually, patients will be given a prescription for a pain
medication to take once they are discharged home. Narcotic medications
are usually only required for the first few postoperative days. It is
preferable to discontinue narcotic use and to take over the counter
medications such as acetaminophen or ibuprofen once these medications
provide sufficient pain relief. If patients are taking acetaminophen or
ibuprofen as well as a narcotic medication it is important to know if
the narcotic pill also contains acetaminophen or ibuprofen — otherwise
patients may inadvertently take too much of one of these medications.Important side effects Most patients receive a prescription for a narcotic pain medication to
take after surgery. There are several side effects to narcotic
medications. These include, but are not limited to: rash, drowsiness,
nausea and vomiting, itchiness, constipation and serious allergic
reactions (anaphylaxis). Patients cannot drive or operate machinery
while taking narcotic medication. It is important for patients to
inform their doctor if they have an allergy to narcotic medications. In
general, narcotics should only be used for the first few days after
surgery, and only when needed.Hospital stay Usually, the patient is placed in a soft dressing and a splint after
the operation, and referred to a hand therapist shortly after surgery.
Patients are usually discharged home on the same day as their
operation, unless there are other complicating medical factors (eg.
heart or lung disease) that require a period of observation in the
hospital.Convalescent assistance Patients can usually go home on the same day as their operation.
Depending on their living situation most patients are able to function
at home with the use of their non-operated hand. In the case of surgery
on both hands, patients may require some additional help at home.Physical therapy After surgery for Dupuytren's disease hand therapy is important in order to maximize the benefits of the operation. Patients should be referred to and followed by a hand therapist who will instruct them in exercises to be done in the post-operative period. Special splints may also be used, and may change as the time from surgery increases. Stitches are usually removed approximately 2 weeks after surgery. Some incisions may be left open to allow drainage. These will heal in on their own with daily dressing changes performed by the patient at home.Rehabilitation options Rehabilitation after surgery for Dupuytren's contracture consists of
hand exercises and splinting. Generally, the patient is referred to a
hand therapist to guide them in this process. The exercises are
designed to work on improved extension of the affected fingers through
active finger motion and stretching. Splints are often used at night to
hold the fingers in an extended position. These interventions are aimed
at maintaining the improved finger motion obtained in surgery, and
lessening recurrence of contractures.Can rehabilitation be done at home? Yes. The hand therapist is there to guide patients in their
postoperative hand therapy, but it is up to the patient to do most of
the work! It is important to have a good relationship with the hand
therapist, and to ask a lot of questions so that the reasons for doing
hand exercises, and using splints are clearly understood.Usual response Hand therapy after fasciectomy for Dupuytren's disease usually allows
the patient to maintain most of the improved finger motion obtained at
surgery. With time, however, approximately 50% of patients will have
some amount of contracture recurrence.Risks There are no significant risks to hand therapy after surgery for
Dupuytren's disease. Sometimes hand exercises will cause an incision in
the hand to partially open up, or may delay healing in an already open
incision. This is not a significant concern, and these areas will heal
in on their own with daily dressing changes.Duration of rehabilitation Rehabilitation usually continues for several weeks after surgery, and
the use of night splints may continue for even longer. As long as the
patient is receiving benefit from therapy, the therapist will usually
elect to continue following the patient. Although frequent visits with
a therapist may not be necessary, since patients can do most of their
therapy on their own at home, it is important to continue to be
followed by a hand therapist until he/she feels that therapy is no
longer necessary.Returning to ordinary daily activities Patients are encouraged to use their hand early in the postoperative
period. In general, after the sutures have been removed (usually 2
weeks after surgery), patients can return to most activities. If some
incisions have been left open, the presence of dressings may interfere
with daily work or recreational activities until the wounds have healed.Long-term patient limitations Once patients have recovered and the period of rehabilitation is over,
there are no restrictions placed on the patient in terms of activities
they can or can't do. Summary of palmar fasciectomy for dupuytren's disease Several different factors, including genetics are felt to be involved
in the development of Dupuytren's disease. The condition cannot be
prevented or cured, and currently surgical treatment represents the
standard of care. The condition can be quite stable over time, or
progress rapidly. Surgery is warranted when the contractures are severe
enough that they interfere with the patient's daily activities, or are
painful. As with all operations there are potential complications. The
condition may recur with time (approximately 50% of cases, though not
always requiring surgery again). Working with a hand therapist after
surgery is vital to obtaining optimal results. References Badalamente, M.A., and Hurst, L.C.: The biochemistry of Dupuyren's disease.
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Elliot, D.: The early history of Dupuytren's disease. Hand clin 15(1): 1-19,
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Lubahn, J.D.: Open-palm technique and soft-tissue coverage in Dupuytren's
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Mikkelsen, O.A.: The prevalence of Dupuytren's disease in Norway: A study in
a representative population sample of the municipality of Haugesund, Acta
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Mikkelsen, O.A.: Dupuytren's disease: The influence of occupation and
previous hand injuries. Hand 10(1): 1-8, 1978.
Mullins, P.A.: Postsurgical rehabilitation of Dupuytren's disease. Hand Clin
15(1): 167-174, viii, 1999.
Rayan, G.M.: clinical presentation and types of Dupuytren's disease. Hand
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Ross, D.C.: Epidemiology of Dupuytren's disease. Hand Clin 15(1): 53-62, vi.
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Strickland, J.W., and Bassett, R.L.: The isolated digital cord in
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Tomasek, J.J., Vaughan, M.B., and Haaksma, C.J.: Cellular structure and
biology of Dupuytren's disease. Hand Clin 15(1): 21-34, 1999. Surgery for Dupuytren's Disease at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4537 to make an appointment.
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