Dupuytren’s disease affecting the hand is a progressive and potentially debilitating condition commonly encountered in the Australian adult population. In most cases, patients learn to live with it, until such time when it begins to intrude upon their activities of daily living. In this article, we’ll take a look at the anatomical basis of the condition, and the various treatment options available.

 

What is Dupuytren’s Contracture of the hand?

It’s fixed flexion contracture of the hand due to palmar fibromatosis. Although most commonly limited to the hand, Dupuytren’s disease can have related conditions such as Peyronie’s disease (of the penis), plantar fibromatosis (of the foot), and Garrod’s pads (of the knuckles). There are no specific causes of the condition; however, a well-known risk factor is its linkage to Scandinavian “Viking” heritage.

 

What are the clinical features?

The disease often begins innocuously as nodules in the palm of the hand. This progresses to development of hard cords along the finger, which “contracts” to form flexion deformities of the affected finger. With an inability to extend fully, this often causes the affected finger to “get in the way” of activities.

dupuytrens1

Dupuytren’s contracture of right little finger, with visible cord.

 

When should you treat Dupuytren’s Contracture?

It is important to not wait too long prior to seeking treatment for Dupuytren’s contracture of the hand. The more flexed the finger becomes, the more difficult it is to regain near full extension through surgery, and the higher the rate of recurrence. In some situations, where the finger is in severe fixed contraction, amputation may in fact offer the best functional outcome.

 

My decision to treat is based general on two clinical considerations. The first is whether the patient’s daily activities are affected by the condition. The second is the presence of a positive “table top test”. This occurs where the patient is unable to place their hand palm down comfortably on a flat surface without interference from the diseased finger/s.

 

What treatment options are available?

Early Dupuytren’s Contracture of the hand can have the option of been treated non-surgically with injection of Collagenase Clostridium enzyme into the diseased cords. This softens the diseased cord, and is followed by forced rupture of the cords. Beyond early disease, surgery is still the mainstay treatment of choice to get a reliable long-term outcome.  Surgery usually involves a combination of fasciectomy (removal of the diseased fascia), release of joint contracture, and possibly skin grafting or z-plasty closure of the skin.  Equally as important in the management of Dupuytren’s disease is post surgery hand therapy, which involves extension splinting, scar management, and range of motion exercises.

dupuytrens3

Dissection of finger, exposing diseased cord, and preserving digital nerves.

dupuytrens2

Removal of diseased cord, and release of metacarpal-phalangeal joint.

dupuytrens4

Closure with skin graft to small skin defect at MCPJ crease.