What is Dupytrens disease?
Dupuytren’s disease is named after Baron Guillaume Dupuytren,, a famous French surgeon who practised in Paris in the 18th century.
It is a disease of the fascia or connective tissue that lies below the skin of the palm. This fibrous tissue is designed to immobilise the skin of the palm to aid grip in comparison to the more mobile skin on the back of the hand.
In Dupuytren’s disease, the normal fascia becomes thickened and forms cords in the palm and the fingers resulting in the fingers becoming fixed in a bent position. It usually begins at the age of 40-50 years but may occur in younger patients, particularly when it runs in the family.
What causes Dupytrens disease?
The cause is unknown. It runs in families, particularly those of Celtic or northern European origin. It is more common in men than women. It occurs more frequently in those with diabetes and those on anti-epileptics. It also occurs more frequently in those with a high alcohol intake.
Various biochemical abnormalities have been found in this condition but the exact cause and any method of prevention are unknown. It is not related to manual work.
What are the features?
The first sign is usually a tender nodule in the palm. The nodule is only painful for several weeks at the onset. The disease is painless after this. The nodule may gradually form a thickened cord under the skin and extend along the palm into the finger, or a new nodule or cord may develop elsewhere in the same or opposite hand.
The rate at which the disease develops varies enormously from person to person. When it begins very late in life it tends to progress very slowly and may never be a problem. When it occurs in younger patients, particularly those with in which the disease runs in the family, it may be very aggressive, causing the fingers to bend down in a flexed position due to the contracting cords of fibrous tissue. The ring and small fingers are most commonly affected.
On rare occasions it may affect the soles of the feet with thickened painless nodules.
Normal fascia of the hand.
How is it treated?
At present surgery is the only way to treat this condition and there is no known way of preventing it or slowing its progress. Research is being performed on the use of collagenase (an enzyme which dissolves connective tissue) injections to rupture the cords of Dupuytren’s tissue as an alternative to surgery. This treatment is not yet available in Australia and its use is limited to certain cases.
Surgery is generally indicated when the finger becomes bent or contracted to a point where the palm or the hand can no longer be placed flat on a table or other flat surface.
Surgery involves removing the diseased tissue from the hand using multiple zigzag incisions.
Following surgery the hand is place in a splint to keep the fingers in the straightened position. Small drains may be used to prevent blood collecting under the skin. These are removed the day after surgery. The sutures are removed 10-14 days after surgery. Therapy is commenced in 3-4 days to prevent the fingers from becoming stiff. A splint may be worn for several weeks between exercises to maximise the correction of the finger deformities.
In severe disease or when surgery has been performed in the same area previously, skin grafts may be required. If this is likely, your surgeon will discuss it prior to your operation.
Despite surgery, the Dupuytren’s tissue can reappear in the same place (recurrence) or occur in other parts of either hand (extension of the disease). Unfortunately trauma such as injury to the hand or surgery to treat the condition itself, may lead to increased activity and progression of the disease. This is particularly common in those with an aggressive form of the disease (young age at onset, strong family history, rapid progress of contracture).
Dupuytren’s disease in the finger, causing the nerve and artery to be displaced from their normal course.
Problems that can occur with the surgery include difficulty with wound healing and small areas of skin loss where the diseased tissue has been removed and left very thin areas of skin. Blood clots (haematoma) can collect under the skin and on rare occasion these may become infected. Occasionally nerves and arteries can be injured as they may be trapped or tethered by the Dupuytren’s tissue.
In most cases it is possible to completely straighten the “knuckle” or metacarpophalangeal joint. Full correction of the contracture in the smaller joints of the finger is not usually possible, but the degree of contracture can be improved in most cases. This sometimes requires more extensive surgery to release the joint. In severe cases, a temporary wire may be placed across the joint to keep it straight for 3-4 weeks following the surgery or occasionally a joint may be fused (permanently stiffened) to prevent it becoming bent again.