| > Site Map |
| Miscellaneous Disorders of the Hand & Upper Extremity > Dupuytren°s Disease or Contracture What is Dupuytren°s Disease? In 1831, a French surgeon named Baron Dupuytren described a condition that produced bumps, or nodules, on the palm or palm side of the fingers. Since that time the disorder has been know as Dupuytren°s disease or Dupuytren°s contracture. The condition is felt to be hereditary although only about one patient out of four can identify a relative who has it. Dupuytren°s disease occurs about six times more frequently in men than in women and has its highest incidence in people with European backgrounds. It tends to be commonly seen in those from Scandinavia, Russia, France, Italy, Ireland, Britain, and Scotland. Nobody really knows the exact cause of the disease but it is often associated with other conditions like bursitis, tendinitis or arthritis. Most of the time there is no trauma related to the development of Dupuytren°s disease. The beginning of the condition is usually unnoticed. At some point in time, a lump or nodule is discovered in the palm. The most common place for the nodule is near the last crease in the palm straight down from the ring finger but it may occur closer to the small finger or at the base of the thumb. The ring and small fingers are the most frequently affected, the long finger next, followed by the thumb. The index finger is almost never involved. Over months or even years other nodules may appear and little indentations or pits may be found near the nodules. When the disease becomes even more active, it may spread from the nodules into the fingers. These extensions are referred to as cords or bands and may be single or multiple. When the cords pass beneath joints they often shorten somewhat and pull the joints downward towards the palm ¬ making it difficult or impossible to fully straighten the finger or fingers. Once the condition has started it may progress very slowly or quite rapidly. As the fingers are bent by the contracting cords, patients will experience some difficulty with those activities that require having the fingers straight ¬such as clapping, putting on gloves or reaching into a pocket. But, because Dupuytren°s disease is usually not painful and because the ability to actively flex the fingers into a fist is never affected, most patients don°t have much trouble with their daily activities. Many don°t even seek medical attention until their fingers are bent down a great deal. The first two joints of the finger are most frequently drawn down by the process. The condition usually involves both hands although it may not appear at the same time and the amount of deformity that may develop can vary greatly between hands. About 20 percent of individuals with this condition have some involvement of their feet and a few others have some thickening over the top of their fingers known as knuckle pads. Unfortunately, there is no known non- surgical cure for Dupuytren°s contracture although there is no harm in gently pushing the fingers into extension periodically in an effort to delay the drawing down of the fingers. No medications, splints or even injections have yet demonstrated any effectiveness although research continues to look for a simple way to manage the problem. For the most part, Dupuytren°s disease that is not producing any drawing down of the fingers should be left alone. The surgery that would be required is too great to justify the removal of nodules and cords that are not causing problems. However, the progress of the disease should be carefully monitored and a physician should be consulted if there is any tendency for the fingers to be pulled down towards the palm. Causes of Dupuytren°s Disease?
Dupuytren°s Disease begins as a small, painless lump that looks like a callus. Physicians may refer to the lump as a nodule. The nodules most likely appear near the crease of the palm at the base of the ring or small finger or thumb. At the beginning stage, individuals may notice the nodules are sensitive to pressure. Gradually, the nodules thicken and contract. Another symptom is the dermal pit. The pit is a small, deep indentation of the skin that develops around the area of the nodule. Usually, pits form in the palm of the hand but can also form on the fingers. Depending on the individual, pits may occur with the first nodule, appear later or never develop at all. A third symptom of Dupuytren°s disease is the cord, which is a long fibrous band that runs from the palm to the finger. Cords are often seen with the nodule but may appear by themselves. It is the cord that creates a contracture and draws the finger into a bent position at either the first or second joint. The disease progresses at its own pace, either slowly or quickly, and may lead to a severe deformity of one or many fingers. The more a finger or fingers contract, the more difficult daily activities become. Examples of daily activities presenting obstacles to patients are putting on gloves, placing their hands in pockets, or grasping large objects. Fortunately, the ability to flex, or straighten, fingers is not impaired. Treatments of Dupuytren°s Disease? Since non-surgical treatment, including splinting, is not effective, a patient suffering from Dupuytren°s disease should consult his or her physician about the advantages and disadvantages of surgery. Choosing to undergo a surgical procedure usually depends on the deformity of the hand and lack of its function. Even if nodules remain on the palm and fingers and pits form in the skin, physicians may encourage patients to weigh the pain and discomfort of the disease against potential complications of surgery. After surgery, patients may experience nerve injury, skin slough where the skin sheds or peels, and even recurrence of the disease. Physicians may advise their patients against having surgery, especially if the nodules are neither tender nor an interference with daily activities. In an exceptional case where pain and discomfort are extreme, surgery may be recommended. Another indicator for surgery is when a person is no longer able to place his or her hand flat on the surface of a table. Each case varies, but the operation is almost always performed under a regional anesthetic and lasts approximately one to three hours. A surgeon°s precision is imperative to protect nerves and blood vessels in the palm and fingers. When operating, surgeons aim to restore maximum hand function to the patient by removing the diseased tissue, not to totally cure the disease. Surgery and Rehabilitation for Dupuytren°s Disease? Zigzag incisions are usually used so that the scars from the incisions will not themselves become a cause for contractures and there are times when transverse incisions are preferred in the palm. Under some circumstances, the surgeon may elect to leave some wounds open and allow them to heal slowly without stitches. Skin grafts may also be occasionally required when wound closure is desired but the wound is too large to close with stitches. The procedure is carried out so that the diseased tissue can be removed as completely as possible without any damage to the tendons, blood vessels and nerves that are so important to the sensation and function of the hand. When the thickened fascia has been removed, any remaining finger joint deformities will also be surgically improved in an effort to make the fingers as straight as possible. A downward contracture of the first finger joint ¬ the metacarpophalangeal or mp joint ¬ where the finger joins the hand ¬ can almost always be corrected by surgery. Deformities of the proximal interphalangeal joint ¬ the middle joint of the finger or pip joint ¬ is not always fully correctable and frequently recurs to a greater or lesser extent. After removal of the diseased tissue, the wounds will be closed with numerous stitches and a small drains will be left in one or more fingers so that any bleeding can be evacuated from the wound. The bandage will be quite large and contain a rigid splint to maintain the wrist and fingers in a straightened position. The drain will be removed in one or two days in the office or at home depending on the preference of the surgeon. Postoperatively, it will be extremely important to keep the entire upper extremity elevated for several days and vigorous shoulder and elbow motion is necessary to prevent undesirable swelling and stiffness. Pain should be well controlled with oral medication. The surgical dressing and splint will be removed at three to seven days and a vigorous therapy program will be started at that time. Because there is a tendency for the hands and fingers to swell and the fingers to get stiff after Dupuytren°s surgery, the therapy will consist of exercises designed to return full motion to the fingers as quickly as possible. Light plastic splints will be made for use between exercises and dressings, which permit finger motion, will be applied in an effort to minimize swelling. The therapy program will include many home exercises and must be rigidly followed or stiffness will rapidly become a problem. Stitches will be left in for two or three weeks because of the slow healing of surgical incisions used for Dupuytren°s disease. Unlike surgeries for other hand conditions, the surgical wounds for Dupuytren°s disease heal slowly and there may occasionally be openings or gaps in the wounds, excessive redness, firm scars and joint stiffness. The use of anti-inflammatory drugs or oral cortisone medications may be of benefit in controlling the post surgical wound reaction for some patients and special pressure pads or splints may be beneficial in softening the scars. Post-operatively, incisions may be tender for several months, healing gradually. At first, therapy may be uncomfortable but should improve with time. Also, a patient°s fingers may be splinted, usually only at night for six to nine months after surgery, to prevent the recurrence of the contractures. The information provided herein is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting a licensed physician. ©2000 DynoMed.com, LLC, Indianapolis, IN |