Dupuytren's contracture
Bent fingers due to dupuytren's contracture can be corrected by fasciectomy surgery
About Dupuytren's contracture
Dupuytren's contracture is a thickening in the palm that prevents the fingers from straightening. It is a common condition that tends to affect older men of european descent. It generally runs in families and patients will often recall an older relative with the condition.
The signs are thickening, nodules and cords in the palms that contract the fingers over time. The fingers normally can close grip easily, however the tight cords prevent straightening of the fingers. The soles of the feet may also be involved, and also the penis may become affect and bend (a urologist can help with this).
It is usually a slowly progressive condition over months to years. Sometimes it will accellerate quickly, and this may be caused by injury or even surgery.
Cause
Dupuytrens is contracture of the palmar fascia, this is the layer of the hand between the skin and the underlying tendons, muscle and bones. In affected people this normal tissue thickens then contracts - effectively tying down the finger!
In advanced disease the joints themselves may become permanently stiff, or nearby joints may become affected and back-bend due to tendon inbalance.
It causes loss of function but it is not dangerous, so does not need to be removed immediately. There is a underlying tendancy in the patient, so when a cord is removed, more cords may form later. Surgery is not preventative.
Should I have surgery?
As Dupuytren's contractures can re-form we don't recommend operating on very early disease. As a rule of thumb, if you can't put your hand flat on a table it's probably time to consider surgery.
Certainly when the first joint of the finger gets bent more than 30° complete correction becomes harder to achieve, joint releases and skin graft may become necessary. So this is often considered a time to consider surgery.
Your surgeon can often achieve full correction at operation, but you need to see the hand therapist regularly for several weeks after surgery to avoid stiffness. During this time you won’t be able to drive.
Ultimately the operation aims to restore hand function and allow you to use the hand normally. Even if you aren’t able to maintain your operative correction after surgery most people will be able to use their hand much more normally and appreciate the better appearance.
Surgery
There are multiple approaches that have different amounts of correction and recurrence rates. Fasciectomy is the most common procedure performed which removes the affected fascia.
The surgery is complex and delicate. It needs to be performed by an experienced surgeon who operates on hands regularly to minimise the risks to nerves and arteries. It requires a lot of time, skill and concentration - using magnification assistance throughout.
After the careful dissection of the diseased cords, the joints may need be addressed if the disease in long-standing. This may require formal joint release, and even temporary wiring of the jionts to hold them straight.
Finally skin deficits need to be addressed. this is usually achieved by multiple local skin advancements and zigzag incisions to achieve this. In severe cases where the finger is tucked in skin grafts, or gaps may be left to heal with new skin.
After surgery you are placed in a plaster splint, and you will need to see the hand therapist within 5-7 days. Even when you have complete correction at operation if you don't work hard with your therapist you will not maintain your correction - even worse you may end up with a stiff hand from disuse. You will need to move the hand as soon as the splint is removed to get the best outcome.
What are the risks of surgery?
The biggest risk in dupuytrens surgery is being recurrence. Partially this is due to the underlying condition. However most patients will only have one operation on a hand in their life. Early recurrence is usually due to not maintaining the surgical correction in the first few weeks with your therapy exercises. Stiffness in closing the hand, or affecting non-operated fingers is characteristic of this.
After all hand surgery there is a risk of CRPS. This is persistent pain and stiffness, heat and swelling after surgery. This is treated and avoided by early active mobilisation. vitamen C is also a helpful treatment. This risk of this is about 1:200.
Wound infection is a low risk, however flap necrosis is possible which may require further skin graft or dressing by the community nurse. If a skin graft is required this does not always take as well and tends to delay mobilization.
Partial correction may be reasonable, especially in advanced disease. Joint releases may make recovery longer and sometimes end up just as stiff. Leaving the joint untouched may allow easier recovery and acceptable functional improvement. This is something you should talk about with your surgeon.
Nerve injury is possible, especially when the diseased cords surround the small nerves to the fingers. injury to these may leave numbness in the fingers affected. Damage to the small arteries is also possible. In revision surgery particularly damage to even one of the two arteries may lead to critical loss of blood flow. This can lead to poor wound healing, skin death or even loss of a finger - although this is very rare.
All this being said, most patient are happy with thier correction as long as they put in the work with their hand therapist to maintain most of their surgical correction.
General advice regarding Dupuytren's surgery
The information here is general and varies depending on individual factors such as: time to treatment, strength of repair, occupation, age and sporting demands.
Will surgery benefit?
when the hand is not flat, or joint more than 30° bent.
Immobilisation
few day in splint only.
Driving
no driving in splint
no driving with hand dressings
Aim for surgery
Remove the contracted cords to improve finger straightening.
Hospital stay
Day surgery only
Return to Work
-
1 handed duties at 2 weeks
-
Full duties whenever comfortable
Investigations
Clinical examination only
Therapy
Hand therapy within the first week
regular appointments 1 month
Return to Sport
-
as soon as comfortable