Dupuytren’s Disease / Dupuytren’s Contracture
Under the skin in the palm of the hand is a firm layer of tissue called the palmar fascia. The function of this tissue layer is to cushion and protect the flexor tendons and nerves as well as to achieve adequate stability when grasping objects.
Dupuytren’s contracture is a disease that causes the palmar fascia to develop thick, fibrous strands and nodules, which leads to finger contraction. It is also known in some places as a type of flexor-tendon shortening disorder. However, the French surgeon, Baron Guillaume Dupuytren, proved in 1832 that the cause was not actually a shortening of the tendon, but pathological changes to the palmar fascia itself.
Primarily, on the ulnar side of the palm, or often on the little finger and ring finger, there are thick nodules and strands. The stages of the disease are classified according to its severity. These range from a tensing of the skin without limitations in movement (stage 0) to complete inability to stretch the finger (stage 4). In stages 0 and 1, a wait-and-see approach is adopted because the disease progresses over years, often intermittently. However, if in stage 2 the fingers are prevented from straightening between 45° and 90° they should be operated on. If an operation is delayed for too long, it can lead to an additional shrinking of the joint capsules and the skin of the hand, which complicates surgery. In stage 4 and under rare circumstances, the only salvage option is to fuse the middle joint or amputate the affected finger.
The disease primarily affects men between 40 and 70 years old. Its presence is likely aided by certain other underlying diseases but this has not been proven. It has increasingly been observed in diabetics, epileptics, people with chronic liver complaints and those consuming high amounts of alcohol. However, it appears that the most likely cause is of genetic influence.
Treatment of Dupuytren’s Disease
There are various treatments available all depending on the stage of the disease and personal circumstances. These range from stretching exercises in the early stages through needle fasciotomy or as described as follows.
A zigzag shaped incision is made in the palm of the hand as well as the fingers in order to prevent the scar tissue contracting. The primary objective is to remove the diseased tissue as much as possible in order to prevent recurrence or delay it as long as possible. Complications include undesirable scar contraction, strong bleeding or dying of the tissue on the edges of the wound. Therefore, only experienced surgeons should perform this operation.
Needle Fasciotomy / Needle Aponeurotomy (NA)
Needle Aponeurotomy (NA) is a relatively quick and mild treatment method especially suited for isolated strands in the hand. It is a small intervention carried out under local anaesthetic, where a needle is guided under the skin to perforate the strand. At the end of the operation or during the following days, the strand extends or snaps. Complete elimination of the contraction can often be achieved in the palm using this method. In contrast to surgical removal, the strand remains in the hand so recurrence of the condition is quicker, but there are only limited restrictions in work or free time activities. Needle aponeurotomy can also be repeated depending on diagnosis, but in the finger area there are limitations to the scope of NA due to the nerve paths.
Lipografting / Skin Grafting
In some cases, the transplanting of the body’s own fat can also help rectify the hardening in the hand. Sometimes a skin graft is also necessary.
A new method is collagenase treatment. This involves injecting collagenase into the strand in order to dissolve a part of it. In comparison to NA, it is supposed that the hand will be recurrence-free for longer. The medicine has been authorized in Germany since May 2011. However, currently this treatment is only possible privately or through individual healthcare services.
After needle fasciotomy, collagenase treatment and operative treatments, stretching exercises and the wearing of a splint or special glove is recommended.
- Self-help group (in German): www.dupuytren-online.de