Dupuytren's contracture
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Baron Dupuytren was a famous French surgeon who described this condition in the early part of the 19th century, although it had been recorded long before that. The condition most often starts with a firm knot of tissue, or nodule, in the palm. This may continue for months or years or it may progress to the next stage of one or more fibrous cords extending into the fingers and pulling them into a bent position. With some people the finger contracture develops without anything forming in the palm first. The initial nodule can be painful or uncomfortable when pressed but later there is usually no pain. The contractures of the fingers may seriously interfere with hand function. There is great variation in the rate of progress but it is usually possible to distinguish the more aggressive form of the condition fairly early on. The little and ring fingers are most frequently affected. The contracture develops mainly from palm to finger, sometimes across the joints within the fingers and sometimes both, it which case it produces a more troublesome contracture. In severe cases it can affect other parts of the body, most often the feet which involves an uncomfortable lump on the sole instead of toe contractures.
The cause of Dupuytren's contracture is not fully understood. It runs in families and in some cases it appears after an injury or operation, but it is not generally accepted that these are direct causes of the condition. It may but that such incidents determine the time of onset of a contracture that was going to happen anyway.
It is important to understand that the abnormal tissue does not involve the tendons that bend the fingers and that fingers can function normally once the contracting bands are removed as long as the joints are still mobile.
Treatment of the early nodule phase (without contracture) has not proved very helpful. Steroid injections into the nodule have been tried but without any dramatic effect. Similarly, the use of splintage does not seem to delay or prevent the onset of contracture. Once Dupuytren's has developed to an extent that interferes with function, surgical excision of the contracting cords is generally felt to be the most appropriate treatment. Surgical treatment is known as fasciectomy and can usually be done under local anaesthetic as a day procedure. Incisions are designed according to the position of the bands but usually take a zigzag line to avoid straight scars which themselves can contract later. The abnormal tissue is removed without damage to nerves and arteries running into the fingers. This can be difficult, especially when the condition has recurred. Damage to these nerves would result in complete loss of feeling on one side of the finger tip but slight patchy loss of feeling may occur temporarily without significant nerve damage.
It is not always possible to restore full straightening to the finger joints even when all abnormal tissue is removed because ligaments holding the joints may have tightened and ligament release may not be possible. Sometimes heavy skin involvement, especially after a recurrent contracture, may mean that some skin has to be removed and replaced with a skin graft. This makes further recurrence much less likely.
After surgery the hand is rested in a bandage. It is very important to elevate the hand in a splint to minimise swelling. A splint will probably need to be worn at night for up to six months. Hand therapy may be started in the first two weeks postoperatively.
Most people regain movement without too much difficulty but determination and persistence are needed. A small proportion of people have difficulty with moving and can have a painful, still hand for some weeks. A few people develop a painful condition called reflex sympathetic dystrophy or chronic regional pain syndrome, with sweating, stiffness and sensitivity to cold.
Dupuytren's contracture is not a fully curable condition. Eventually recurrence is likely in some form elsewhere in the hand or in the same area but the correct approach is to maintain function and mobility as far as possible, accepting that further surgery may eventually be necessary.