Dupuytren's contracture

Definition

This is a disease of unknown origin which affects the aponevrosiss, i.e. the fibrous envelopes between the skin and flexor tendons of the hand. These structures thicken to form lumps and cords and lead to folds in the palm and fingers and an associated retraction, causing loss of finger extension.

At the worst stage of the condition, the fingers can become completely closed into the hand. It is a disease that evolves over time, and may develop at varying speeds, ranging from a few months to several years.

Cause

This disease is partly genetic in origin. Often, several members of the same family are affected by this disease in its varying forms. Several diseases are associated with Dupuytren’s Disease, such as epilepsy, diabetes, hypertriglyceridemia, and it is linked to smoking and alcohol consumption. Manual work is not a direct cause of Dupuytren’s Disease.

Diagnosis

Diagnosis is clinical through observation and palpation of the cords or nodules in the palm of the hand or on the fingers. The earlier the disease occurs, the more serious it is. Complementary examinations are not necessary unless associated carpal tunnel syndrome is suspected.

Treatment

For the moment there is no medical treatment.

In cases with a well-individualised sub cutaneous bride, treatment by a sub cutaneous sectioning of the bride using a needle may be the recommended course of action.

The advantage of this technique is that through this simple gesture, good finger extension may be recovered, even though it does not allow for the removal of the complete retracted aponevrosis.

In more severe forms, and with deficient finger extension, surgery is the recommended solution. The latter consists in opening the hand to remove all of the affected tissue. In simple terms, treatment is recommended when the patient is no longer able to lay his hand flat on the table. The further the disease is developed, the greater the difficulty and risk involved in the treatment.

Surgical procedure

• Length of hospital stay: outpatient to 2 days.
• Anaesthetic: loco-regional
• Immobilisation: no, extensive dressing 2 to 15 days

The procedure is performed under regional anaesthetic.

A tourniquet is placed at the root of the arm to prevent bleeding. One or several zigzag incisions are made on the palm of the hand and the affected fingers. After freeing the nerves, vessels and tendons, the retracted aponevrosis are removed. The skin is then sealed using well spaced sutures to allow for the evacuation of any haematoma that should occur.

Extensive dressing is applied for 2 days and is then changed every 2 days by a nurse visiting the patient’s home. Extension splints may be prescribed for the first two weeks following the operation in more serious cases.

After-surgery care

Dressings are to be changed every 2 days by a nurse visiting the patient’s home. Scarring is often hard and inflamed for several weeks. Tingling sensations in the fingertips may persist for several weeks. Once the scar has healed, physical therapy may be required for several weeks or months to enable the patient to recover the full range of hand movements.

Depending on the gravity of the initial condition, it is not always possible to recover complete finger extension.

It may be necessary for the patient to stop work depending on the extent of the disease and the nature of the work itself.

Possible complications

• Difficulty healing which can require dressings for a longer period or even more surgery.
• Lesions of the nerves, possibly leading to persistent tingling sensations or to a loss of sensitivity in the fingers.
• Lesions of the vessels, which may necessitate amputation of the finger, particularly in the more developed forms of the disease.
• Algodystrophy, may develop, i.e. swelling and pain in the hand, followed by transpiration and persistent stiffness lasting several months or years.
• Recurrence is frequent in the same place or at another site in this type of affection.