Guillaume Duypuytren was a French surgeon who described the condition in 1831. It is a disease that fascinates both the sufferer and the surgeon.
Dupuytren’s disease is basically a thickening of normal fibrous tissue of the hand that contracts over time and creates palm, finger and joint deformities. It is much more common in men (9:1) and seen more frequently in the Caucasian race, especially those of Celtic and Scandinavian origins. There is some association with diabetes, high alcohol consumption, smokers, hypercholesterolaemia and seizure disorders.
The quintessential cell or culprit in this complex disease is the myofibroblast. “Myo” refers to muscle or the ability to contract, and fibroblast is the cell that creates collagen and forms part of all connective tissue. The abnormal cells create diseased connective tissue that has the ability to contract. This diseased tissue then consumes the normal connective tissue planes of the hand.
It is important to understand that the hand has a very specialised connective tissue framework that enables the hand to withstand high torsional forces and the skin to grip objects firmly. There is a complex, well defined anatomical fascial complex on the palmar side of the hand. There is a central aponeuroses, (in the palm of hand), palmodigital fascia (that connects the palm and fingers) and the digital fascia. These structures are composed of very specific well defined bands. When these normal structures (bands) become diseased in Duyputren’s disease, we call them chords.
It is these chords that create the problems in this condition and they develop progressively in a predictable fashion. Dupuytren’s disease not only creates nodules and pits on the skin, but creates joint flexion deformities: The palmar chords progress to bend the knuckle joints. Furthermore, the spiral chord (which is a palmodigital chord) creates further trouble as it runs in a spiral fashion, entangling the artery and the nerve of the finger. The lateral chord in the finger is thought to be the culprit creating a rigid flexion deformity of the first joint of the finger (Proximal interphalangeal joint). The most common finger to be involved is the ring finger, followed by the little, middle, index finger and finally the thumb.
There is no quick-fix for Dupuytren’s disease. Non-surgical options have been investigated but none of them are superior to surgical management in advanced disease. Collagenase (an enzyme that dissolves connective tissue) is currently used in selective cases as a non-surgical method to dissolve well defined palmar chords. Xiaflex® is currently not available in South Africa.
Surgery is a good treatment method and should be timed well and applied to the right patient. Not all disease is progressive. Progressive diseases create more disability in activities of daily living and eventually create hygiene related problems. These patients should be considered for surgery. There are no black and white rules but it is generally accepted that a flexion deformity of the proximal interphalangeal joint beyond 20 degrees with or without 30 degrees flexion deformity of the metacrpo-phalangeal joint, are considered to be good candidates for surgery.
Surgical options range from percutaneous needle fasciotomy where well defined chords in the palm are cut by percutaneous needles. In the same token, intra-operative fasciotomies (cutting of fascia) yield good results.
In advanced cases, the diseased tissue should be excised in an operation that is called a fasciectomy. Additionally, the skin should be lengthened by Z-plasties to obtain increased length of the skin that has become shortened by disease. Compliance with rehabilitation is strongly recommended to obtain the best functional outcome after surgery.
Rehabilitation post Dupuytren’s Contracture release / Fasciectomy
The hand and wrist is immobilised in a cast for 7-10 days, to allow the wounds to heal. Post surgery, it is important to keep the hand elevated and the cast dry.
When the cast is removed, the wound will be checked and re-dressed. The stitches come out approximately 14-20 days post surgery. A forearm thermoplastic splint is fabricated to maintain the straightening of the fingers. Initially, this is removed only for exercises and should be worn full time until the wound has healed. Thereafter, it must be worn at night until 3 months post surgery to prevent recurrence of the bent finger/s.
Exercises are usually started at the first post surgery appointment. Early movement of the fingers will minimise scar adhesions and stiffness. Therapy will address swelling and scar management, and help to regain movement, strength and function in the hand. It is important to be committed to the rehabilitation process for approximately 3 months, to achieve the best outcome.