DUYPUYTREN’S CONTRACTURE


What is Dupuytren's contracture?

Guillaume Dupuytren 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 aponeurosis, (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 Dupuytren’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 in the ring finger, followed by the little, middle, index finger and finally the thumb.

What are Dupuytren’s contracture symptoms?

Dupuytren’s contracture progresses slowly over the years and occurs as a thickening of the skin on your palm. As it progresses, your palm's skin may appear to be puckered or dimpled. There may be a lump on the palm of your hand which may be sensitive when touched but is not normally painful. In later stages, the cords of tissue may tighten, resulting in your fingers being pulled towards your palm.

How is Dupuytren’s contracture treated?

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 the hand surgeon uses percutaneous needles to remove well-defined chords in the palm. In the same token, intra-operative fasciotomies (cutting of fascia) yield good results.

In advanced cases, the diseased tissue should be excised in a hand surgery called a fasciectomy. Additionally, the skin should be lengthened by Z-plasties to obtain an 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 doctor will immobilise your hand and wrist with 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. Dr van der Spuy will fabricate a forearm thermoplastic splint 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 three months post-surgery to prevent recurrence of the bent finger/s.

Exercises are usually started at the first post hand 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 of the hand. It is important to be committed to the rehabilitation process for approximately three months to achieve the best outcome.

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