DUPUYTREN’S CONTRACTURE (PALMAR FASCIITIS)

Dupuytren’s contracture is a thickening of the tough tissue called fascia that lies just beneath the skin of the palm. The tendons are normal but the Dupuytren’s tissue may wind around the sensory (feeling) nerve and artery to the finger. Knuckle pads (thickenings) over the back of the finger joints are seen occasionally. The loose skin of the back of the hand does not become involved.

Dupuytren’s is genetically determined but this is not always apparent as the gene mix varies in many ways with each generation. The gene originated in northern Europe and spread – possibly with the Vikings. A strong family history and early onset may indicate a more aggressive disease pattern. Epileptics and diabetics may be more prone to it. Deformities of the ring and little fingers are the most common, however all the fingers and thumb can be involved as well as the sole of the foot.

 

Treatment Options

NO TREATMENT

Small nodules or lumps in the palm do not need treatment until they are large and interfere with hand function. There is no treatment to date that is curative and therefore we do not recommend treating the Dupuytren’s tissue unless it is causing functional problems. Will exercise / stretches help prevent the contracture worsening? Once again at this stage there is no evidence for or against massage or stretching exercises.

Treatment is usually indicated when you can no longer put your hand flat down on the table.

CORTISONE INJECTIONS

Cortisone injections may help improve discomfort from a small painful palmar nodule but do not significantly influence the development of the disease.

COLLAGEN ENZYME  INJECTIONS

This is the most recent addition to Dupuytren's therapies and is now available in Australia. The finger cords are targeted by a non-operative method injecting an enzyme that dissolves Collagen ie the thick scar like bands beneath the skin. This enzyme weakens the cord which then, in a next step, can be pulled and mechanically broken. Bent fingers thus become straight and functional again. A splint then needs to be worn at night for up to 4 months. Early results with this treatment are encouraging with 64% patients achieving nearly straight fingers after a course of treatment and overall 84% patients improving their contracture. At 3 years though about 30% patients have redeveloped >30 degrees contracture at a joint and complications with the treatment have been reported (commonly-local irritation and bruising / rare-tendon rupture). Joints with less severe contractures are more likely to respond to treatment than joints with more severe contractures, indicating that early intervention may be the most effective treatment approach. Similar observations have also been reported in the surgical literature. Delaying treatment makes surgical correction more difficult.

NEEDLE FASCIOTOMY

When the Dupuytren’s disease is principally limited to the palm but the finger is starting to pull up at the metacarpophalangeal joints (the first knuckles nearest the palm), under some sedation in hospital a hypodermic needle can be used to cut the band in several areas so that the finger can be straightened out further. This puts breaks into the band but does not excise any of the abnormal tissue. It is a more minor procedure, with a quicker recovery time but recurrence of the contracture is more likely to develop within a couple of years than a fasciectomy. Appears to give similar results to the Collagenase injection.

FASCIECTOMY SURGERY

Surgical excision of the thickened fascia is the most effective treatment. The initial surgical treatment should be delayed until one or more fingers become bent, but not so long that any finger joint is fixed more than 45° or so the hand cannot be pressed flat on the tabletop.

 

Your Operation

Fasciectomy surgery is performed in Hospital. A general anaesthetic is usually required as the surgery is often extensive. Incisions are usually made longitudinally down each finger over the abnormal bands. The nerves and arteries to each finger are carefully dissected out and protected against damage and then the diseased tissue can be removed. The overlying skin is often contracted and tight and therefore the skin will need to be lengthened with multiple Z shaped incisions. The wound is then sewn up with dozens of fine sutures that will usually need to be removed two weeks later. If the wounds go down the fingers or if you are on blood thinning medications, small plastic drain tubes may be placed into the wounds to drain away any further blood that may ooze from the raw tissue.

If the skin is very tight and there is insufficient to close the wound, a full thickness skin graft may be required. An ellipse of skin is taken from the inside of your arm or forearm and this wound is sewn up in a straight line. The “dead” skin is then stitched into the area lacking skin on the finger or palm. Over the next week new blood vessels will grow into this piece of skin providing it with circulation. The use of a skin graft is also indicated when the disease is very aggressive, especially if recurrent as it may prevent the disease from coming back in that area (Dermatofasciectomy).

When fingers have been bent for a while, the finger joint ligaments frequently contract limiting the ability to fully straighten the fingers, even with surgery. Sometimes a degree of bend of these finger joints cannot be corrected without cutting the joint ligaments. If these are cut, then bending of the finger may be interfered with and thus a slight residual bend is often the preferable outcome.

 

After The Surgery

Depending on how extensive the surgery is, you will either be done as a day case or you will be kept in hospital overnight and if drains have been used these are usually removed the next morning prior to your discharge from hospital. The hand will be bandaged and splinted for one week after the surgery, during which time use is very limited and the hand should not be put in water (i.e. place in a plastic bag for showering). The hand needs to be kept elevated i.e. walk with it held up during the day +/- use a sling if going out, and sleep with it on a pillow overnight.

Stitches are usually removed after 2 weeks. Overall, hand use is reduced for about 4 - 6 weeks, with full recovery expected by 3 – 4 months. In the first few weeks you will be unlikely to be able to make a full fist and gripping objects will be difficult. Patients with the Dupuytren’s gene often exhibit quite an “angry” healing response in the hand with thickening and redness persisting for months. This settles in time and is not a reflection of inadequate surgery.

Postoperative result 6 weeks post needle fasciotomy to palm and limited fasciectomy in the little finger.

Hand therapy is an integral part of the postoperative period. The aims of therapy are to assist with scar management and movement through a program of daytime exercises, compression to reduce swelling, ultrasound and/or iontophoresis (application of a corticosteroid via an electrode) to break down scar tissue. For 3 to 5 months postoperatively, splintage is used at night to help maintain the correction along with silicone gel to soften the scar.

Risks include anaesthetic complications, bleeding or infection of the wound. Specific complications include numbness near the surgical incision or along one side of the finger due to nerve damage, swelling and stiffness of the fingers or Complex Regional Pain syndrome. This is the development of a burning sensation and sharp pain that becomes much worse than normally expected for the degree of surgery. If it occurs, the syndrome usually settles down in a weeks to months, though in some cases, it may persist and require pain management. Recurrence of the Dupuytren’s contracture may develop with approximately 10% of patients requiring further surgery by 10 years. The thin skin that remains after excising the Dupuytren’s disease has reduced circulation and can exhibit slow healing, or small areas skin loss which may require dressings for several weeks to heal or in severe cases, circulation to the finger may be inadequate and the finger may be lost.