Dupuytren’s contracture

Sinonimi: Morbus Dupuytren, Dupuytren’s syndrom, Dupuytren’s disease, Palmar fibromatosis

Contracture of a finger or fingers of the hand with the inability to extend them because of the formation of subdermal lumps and bands in the palm and fingers as well.

Dupuytren’s contracture is a condition in which a permanent flexion of the fingers towards the palm occurs, with an inability to extend them (contracture). In the palm, and often in the fingers, thickenings develop in the form of subcutaneous lumps and bands. The disease usually occurs after the age of 40, at first as a solitary nodule in the palm, and then the thickening gradually extends throughout the palm and fingers, thus presenting as permanently flexed fingers.

Reason for developing it is not entirely known.

What we do know is:

• That the basis of the disease is in a fibrous degeneration of the palmar fascia (palmar aponeurosis)
• That in a certain number of cases there is a hereditary component
• That it occurs more often in the setting of diabetes, epilepsy and alcoholism
• o That sometimes it occurs immediately after hand trauma

It is unknown to what extent microtrauma influences the occurrence of the disease. (small negligible injuries of the hand).

• Subcutaneous thickenings in the palm
  The first sign of developing disease is an occurrence of one or more subcutaneous thickenings in the palm, in the form of grainy bumps that are palpable. There are no functional hindrances at this stage, nor usually any pain.

• Subcutaneous bands in the palm
  During further development of the disease, subcutaneous bands appear, like “strings on a violin”, always vertically across the palm and travel in the direction of the fingers. At this stage of the disease, first signs of involuntary finger flexion appear, but functionality is preserved, overall
  Disease usually appears in the palm, in the path of the ring finger, with the little finger following, and the middle finger being the last one affected. However, the disease can start in any finger, and in rather larger than smaller number of cases, only the little finger and the thumb are affected.

• Reduction in hand functionality
  When a more significant palmar flexion of the fingers happens, patients usually complain on the loss of personal contact because they are unable to shake hands with other people, they feel awkward in every day communication with other people. Of course, there is also a significant loss of functionality in performing precision manual labour.
• Pain and discomfort
  Pain doesn’t present a major part of this disease, but it’s present during manual operations. However, discomfort during work is more common.
• Subcutaneous thickenings in other regions
  In a small number of cases, except for palms, the disease can appear in the soles, sometimes in knees, even in the penis.

Dupuytren’s contracture often occurs in both hands in one person.

The development of the disease, from the first nodule to complete palmar flexion of the finger or fingers, with a loss in function, usually takes several years (even 5 to 10), and rarely it can progress inside one year.

In most cases, a detailed clinical examination of the subcutaneous thickenings with a flexion-extension function test is enough. Both hands and functions of all fingers should be examined in all cases, as well as other body regions where Dupuytren’s disease occurs.

Dupuytren’s contracture has a constant progression in most cases. Other than the condition evolving, there are no known complications.

Treatment is not necessary in cases where there are no functional problems.

When there are functional issues or loss of quality of life over every day discomfort, the following treatments are available:

• Hand immobilization
  Immobilization of the hand during the day or during the night is only one of the possibilities, but with no significant success.
• Injection treatment
  Injecting with collagenase, steroids and 5% fluorouracil, directly into the nodule can be useful in some cases. Value and performance of such treatment is still under evaluation.
• Radiation therapy (X- rays)
  Use of low dosage X-rays is also an option under evaluation, but is often accompanied with skin related side effects (skin damage, dryness and similar)

• Surgical treatment is advised in all cases when the contracture of the joint between the finger and the palm is greater than 30° or
• When the contracture in the middle joint of the finger (PIP-joint) is greater than 10°

Surgical treatment is based on the following three techniques:

• “open fasciotomy”
  This is a relatively simple procedure which is conducted under local anesthesia. Small incisions are made on the skin, through which the fascia is accessed, specifically the subcutaneous thickenings which are severed, thus interrupting the continuity of the string that pulls the finger towards the palm, and making the extension of the finger possible.
• “closed fasciotomy” (needle fasciotomy, needle aponeurotomy)
  This is the least invasive technique, that is also conducted under local anesthesia. A needle is inserted directly into the subcutaneous thickenings, and by moving the needle along the width of the band, small microtraumas are made, that enable the finger to be released from the fixed position (contraction) by use of a sudden extension.
  Use of this particular technique has it’s limitations:
  • It’s not useful in cases of more severe contractures,
  • Nerve and blood vessel damage is possible, and accompanying problems that go with it
  • Reoccurrence of the contracture (in the next 3 to 5 years)

  However, keep in mind that the procedure can simply be repeated
  .

• Limited fasciectomy
  This is the procedure that’s been in use the longest, and it still holds a place in the indication pool, especially in cases of severe contractures and in cases where the previous 2 techniques were not effective. Limited or partial fasciectomy entails the removal of all subcutaneous thickenings (nodules and bands) but that also means creating a soft-tissue defect. Based on how the created defect is resolved, limited fasciectomy can be:
  • Open fasciectomy
    When the defect is left to heal spontaneously. Average healing time is 3 to 4 weeks and
  • Closed fasciectomy
    When the created defect is resolved by using one of the closing methods:
    • Primary suture (direct closure) or
    • Use of a skin transplant (Skin Graft technique) A skin graft taken from some other region is placed and fixed over the made defect.