Back to Hand Surgery IndexDupuytrens Contracture is a condition of the hands that is genetically determined. More that 80% of patients with the disease have a relative with some form, even mild, of the condition. It is thought to be more common in those of Celtic or Viking extraction and can vary enormously in its severity.
Dupuytrens Contracture affects the gristle layer (fascia) that lies beneath the skin of the palm and whose role is to bind down that skin to prevent it from skidding about the way the skin on the back of the hand does. Without this tight adherence of the palm skin to deeper structures we would find it hard to grip anything without some movement. The disease first makes its appearance as either a small pit in the palm, often in line with the ring or little finger, or else as a small lump, usually (but not always) in the same palmar location. This lump may be sore, but may remain unchanged for many years. For reasons we do not yet know, the lump may then form a band or cord of tissue that runs along the finger, and which can often be felt through the skin. Over a period varying from months to years, this cord begins to shrink and so to draw the finger inexorably into a clawed position. This is the contracture, and as it progresses so does the nuisance and disability associated with it. In addition the disease may begin to affect adjacent fingers or fingers on the opposite hand. At this early stage surgery can correct the contracture, particularly if it has afflicted the knuckle joints at the junction of palm and finger (metacarpophalangeal joints: MCPJ). If the middle joint (proximal interphalangeal joint: PIPJ) of the finger is affected, correction is more complex and delay incurs more of a penalty in terms of less than full correction. It is for this reason that surgeons like to have the opportunity to examine the hand at an early stage of the disease, and as a general rule, if you are no longer able to place the hand palm down flat to the table with all of the palm in contact with the table-top, then you should seek advice.
The same condition can vary greatly from person to person, and in some it may be mild and not progress at all, whilst in others it may progress rapidly and in rare cases may even affect the feet and other sites. In general the younger the age of onset of the disease the more likely it is to progress and the more demanding its correction. In very rare cases Dupuytrens Contracture may be provoked by a single injury, but a relationship with hard work or manual labour has not been established.
Surgery is the only effective treatment at the present time. Drug remedies have been tried but so far have failed, and splinting has not been shown to be effective on its own. Surgery can be accomplished either with the arm itself numbed or anaesthetized, or with the patient asleep. Admission and discharge the same day is common. In mild cases the contracture can be corrected through a zigzag scar on the palmar surface of the palm and finger(s) through which the diseased tissue is removed and the joint freed. Following surgery the wound is closed, but some transverse elements of the scar may be left open, not as an oversight but because they allow blood to drain rather than collecting beneath the skin, and they heal as well as if they were stitched. A dressing is applied and the hand rested for 1 week in a splint or cast.
In more severe cases especially if the disease has recurred after previous surgery, or if the signs of very active disease are present, or if the skin is very closely involved in the diseased tissue, then it may be necessary to remove the overlying skin and replace it with a skin graft taken from either the inner aspect of the arm or from the groin. This is actually a very simple and reliable technique, that replaces diseased skin, and adds skin where the contracture has allowed the existing skin to "shrink" down. But skin grafting has one other surprising effect: it seems that recurrence of the disease almost never occurs beneath a skin graft for reasons that we don't understand.
This is important because one of the vexing problems with Dupuytrens Contracture is that of recurrence. In the predisposed individual surgery to one finger may be followed by recurrence in another finger or even on the original finger, and this latter can be prevented by skin grafting. The judgement as to whether a skin graft is warranted or not will be discussed with you.
After surgery you will be seen at one week and the dressing changed and the splint removed. (If before that time you have any anxieties about your dressing being too tight or your hand becoming more painful please contact your nurse or surgeon immediately). Exercise may then begin, and for the first 2 weeks I emphasise the need to regain as much straightening of the hand as possible. The stitches are usually removed at 2 weeks. After 2 weeks I like to you to begin more emphasis on curling the fingers (flexion), and you will be instructed in this area. Some patients (about half) benefit from physiotherapy advice and treatment during this period.
With time the scars become more supple, and the hand regains its mobility, but occasionally I like to place one of a variety of splints on the hand, especially at night, to assist this process.
Dupuytrens surgery is reliable and predictable by and large, with few complications. Like all wounds, there is a small risk of bleeding or infection, but this is rare. Skin grafts very occasionally heal poorly and require further minor surgery, but this is most unusual. Injury to one of the small nerves of the hand can occur, especially in complex or recurrent cases, but again is unusual. This would produce some numbness in the fingertips that usually improves with time but may persist in slight degree for ever in a very few cases.
A more serious, albeit rare, complication of surgery is an unpredictable and poorly understood condition called reflex sympathetic dystrophy in which the hand swells, becomes red, and may develop a burning type of pain. This condition varies from very mild to severe, but can be treated if recognised early. Its cause is not known and it afflicts a very small percentage of cases, but in extreme forms can lead to stiffness of the hand. I am always vigilant for signs of the condition and instigate treatment immediately in the very few patients that develop it.
Finally, complete correction of long standing or recurrent joint contractures cannot always be achieved, and for this reason, and because recurrence is common, I recommend that you report new disease as early as possible so that it can be carefully evaluated and monitored, and surgery planned at a stage when it is most effective.
Professor Simon Kay, Consultant Plastic Surgeon
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