Richard A. Bernstein, MD
Dupuytren's disease is a condition that affects the palm of the hand, forming contracted cords. It is more common in men and found most commonly in people with a Celtic genetic background (Irish, Scottish, Scandinavian, Northern European), although it is found in people of many different ancestries. It affects the connective tissue in the palm known as palmar fascia (normal tissues are shown in the illustration at the right), which is the tissue that helps stabilize the palm skin. The palmar fascia starts near the wrist, divides into bands (known as “pre-tendinous” bands) as it goes to the fingers.
It can then split into two bands that attach to the natatory ligament and into the sides of the fingers.
Dupuytren’s contracture is a fairly common condition that occurs when the connective tissue under the skin (specifically, the pre-tendinous bands of the palmar fascia) begins to thicken and shorten. As the tissue tightens, it may pull the fingers down towards the palm of the hand. In some individuals, the condition may progress until the involved fingers become disabled.
People of northern European descent. There is a strong genetic component to Dupuytren’s contracture, although not all patients are of northern European descent.
Men. The incidence of Dupuytren’s contracture is about seven times higher among men than among women.
People of middle age. Most of the time, Dupuytren’s contracture doesn’t show up until after age 40. However, a very aggressive form may rarely appear in teenagers and children.
The first sign is a thickening (nodule) in the palm of the hand that most frequently develops near the base of the ring or little finger. The nodule, which can resemble a callus, is painless but may be tender to the touch. Gradually, a thickened tissue of palmar fascia forms from the pre-tendinous band and becomes a cord. This may extend across a joint, causing a contracture as the cord shortens. The overlying skin begins to pucker, and cords of tissue extend into the finger. As the process continues, these cords tighten and pull the finger in toward the palm. The ring finger is usually affected first, followed by the little, long and index fingers. The problem is not pain, but the restriction of motion and the deformity it causes.
The progress of the disease is often sporadic and unpredictable. Exactly what triggers the formation of nodules and cords is unknown. As the disease progresses, the diseased tissue wraps itself around and between normal tissue. Many people do not seek medical care until the contracture is well advanced. Until recently, the only treatment for this condition is surgery, which is usually reserved for individuals who have developed deformity as a result of the progressive contracture. New nodules do not necessarily progress to contracture and because scar tissue from previous surgeries can make excision of recurrent nodules more difficult, surgical removal of isolated nodules is not indicated in most cases.
A good guideline for determining when to consider surgery is the "table top test." Try to place the palm of your hand completely flat on a hard surface. If you can’t, the contracture has progressed to a point where surgical intervention could be helpful. Dupuytren’s can also be associated with thickening of the knuckles on the back of the hand or thickening of the tissue on the sole of your foot. Men can rarely get a band of tissue in their penis, called Peyronie's, if so we can have you see a Urologist who specializes in that.
Unfortunately there are no splints, exercises, pills or simple “cortisone” injections that can improve the course of Dupuytrens. Many of these techniques have been tried without success. Xiaflex is an injection that was FDA approved in 2010. It is an enzyme based on the Clostridium bacteria. The medication has been studied and trialed, and has undergone numerous studies on its efficacy in treating certain cases of Dupuytren's. Xiaflex does not “get rid” of the Dupuytrens; it helps erode the cord so that the cord can be broken to correct the contracture. There are risks that include a flare reaction, tendon rupture, skin tear, nerve injury, and recurrence. The best contractures are bands at the MP joint and those with a centraI band. Bands and contractures that extend to the PIP joint also respond to Xiaflex, but not as successfully as an MP joint contracture. I have used Xiaflex extensively and have presented results at the American Society of Surgery of the Hand meeting and will be happy to discuss whether your Dupuytrens is a candidate for the medication. In my experience, when you are a candidate, the results have been gratifying and much easier for my patients to recuperate from than surgery.
When surgery is needed, every case has subtle differences and we can discuss the techniques based on the extent of the contracture and disease. The aim of the surgery is to release the contracture and improve hand function by removing the diseased tissue. The results of surgery are usually good, and the fingers can return to good extension after therapy. You need to be dedicated to your post-operative therapy. Probably more than any other condition I treat with surgery; you need to be dedicated to wearing a splint, doing your exercises and working with a therapist. If you are not going to be able to wear the splints and exercise, it is not worth having the surgery. Some studies suggest night time splinting for 6 months after the surgery. However, the disease can return even some years after the initial surgery. Dupuytren’s contracture usually does not recur beneath a skin graft, so this may be an option in especially aggressive forms of the disease. There has also been a resurgence in another option based on a Scottish surgeon, termed the McCash technique. This involves intentionally leaving open part of the incision at surgery. By leaving it open it diminishes tension on the skin and decreases the chance of a blood clot (hematoma) developing under the skin. In severe contractures, this is a technique that I may discuss with you for in some cases it is a better option than putting a lot of tension on the skin. The skin heals on its own within 2-5 weeks depending upon the extent of the open area; the therapist and I will discuss how to care for your hand.
It’s important to keep the appointment for hand therapy after surgery. You will have to wear a splint so that the fingers stay extended during the day and at night. The splint is usually worn full time immediately after the surgery and then only at night for several months. You will also have to do some active range of motion exercises so that the finger retains mobility and strength.
This is the incision of a Dupuytren’s patients about two weeks after surgery on the palm and fifth finger. Note how he can fully straighten out the finger.
Many patients ask about return to work activities after a Dupuytren's release. Everyone is different, but here are some guidelines. I encourage you to return to any activities that you want as soon as the dressing is off, as long as the hand remains clean and dry. Keyboarding, playing a musical instrument for instance are both great therapies to help restore hand function. These are only rough guidelines which will give you some idea of what to expect.
Copyright © 2010, TOG All rights reserved
Gail Garfield, OTR/L CHT
Dupuytren’s Disease is a progressive disease of the overlying skin and fascia of the palm and digits of the hand. There is no definitive cause of this disease; however, a possible northern, northwestern European origin is speculated. With this disease, there seems to be a greater prevalence in men than women with an onset age between 40-50 years. This disease is known to be associated with alcoholism, diabetes, some seizure medications, carpal tunnel syndrome and tenosynovitis.
Dupuytren’s Disease is the production of collagen from fibroplastic cells which causes a hard lump or pitting in the palm. Depending on the extent of the disease, the palmar and digital fascia as well as their entire structures, contract. Once a cord has formed, the large knuckle (MP joint) of usually the 4th or 5th digit is the first to contract. A pretendinous cord can also be present in the web space and/or thumb of the hand. As the disease progresses, a shortening and pulling of all the structures causes the middle knuckle (PIP joint) to further contract the finger into a flexed position.
Typically, a person notes a decrease in function of their hand with having difficulty putting their hand in their pocket, poking themselves in the eye when washing their face as well as decrease strength and ability to open their hand to grasp an object. A flexion contracture of the large knuckle (MP joint) of 30° or more or 15° or more of the middle knuckle (PIP joint) is sometimes an indication that a surgical release is needed.
There are various surgical techniques used to remove the disease tissue and correct the hand deformity. A fasciotomyis the most common technique used today, a series of diagonal incisions, sometimes requiring a Z-shaped incision (Z-plasty) in the palm to remove the diseased fascia and release the large knuckle contractures.
Postoperative therapy usually begins 5-7 days following surgery. An OT or PT certified hand therapy typically takes off the postoperative dressing. Evaluation and treatment goals are established at that time, and the patient is instructed on a comprehensive home exercise program. The initial goals are maintaining digit extension as well as edema management and wound healing. For the next 4-6 weeks after the surgical release, depending on the severity of the disease, the patient will be managed by their therapist to achieve maximum hand function, and to return to their Activities of Daily Living (ADL). is the most common technique used today a series of diagonal incisions, sometimes requiring a Z-shaped incision (Z-plasty) in the palm to remove the diseased fascia and release the large knuckle contractures.
Splinting is an important component to maintain the digital extension that was achieved in surgery. At the first visit with the therapist, a dorsal hand-based splint is fabricated to help maintain the digits in extension. The splint is worn initially at all times except for hygiene and while performing exercises. This splint schedule is continued during the wound healing and scar formation stage (approximately 2 weeks). Promotion of functional use of the affected hand is important upon suture removal, Therefore, discontinuing the splint during the day and wearing the splint only for night time is encouraged. Continued splinting is recommended for up to 6 months following surgery to maximize digit extension during the scar maturation process.
Edema management is critical for healing following any hand surgery. It is imperative that the postoperative swelling be managed after a Dupuytren’s release as to avoid further contractures in the finger joints. The patient is instructed on various techniques such as elevation, retrograde massage and coban wrapping to keep swelling to a minimum. Range of Motion exercises are initiated at the time of the initial evaluation. Active and Passive exercises of the affected digits as well as tendon gliding exercises are instructed as to promote joint motion which will aid in decreasing scar adhesions, decreasing swelling (edema) in the hand, decreasing joint stiffness and contracture while increasing tendon gliding.
Scar management begins immediately after wound closure. Deep friction massage to the palm and affected digits, prolonged stretching, silastic gel inserts and modalities such as ultrasound are a few techniques that can be used to remodel or soften the surgical scar.
Strengthening exercises are generally introduced 4-6 weeks following a surgical release. Progressive resistive exercises should focus on returning one to work or to their maximum level of functioning. Activities of Daily Living are assessed to ensure complete return to functional independence.
Dupuytren’s Disease is challenging disease which requires good communication among the patient, physician and therapist in order to obtain a positive outcome and return the patient to full functional mobility of their hand.
© 2008 The Orthopaedic Group, LLC
Not to be reproduced without the express permission of the author