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Dupuytren's contracture

Dupuytrens contracture

Dupuytren's contracture is a common hand condition seen in Europe. There is a strong familial tendency suggesting a strong genetic predisposition but with sporadic inheritance. The palm of the hand is much tougher than other parts of the arm and this is due to an extra layer of tough fibrous (scar-like) tissue just under the skin and above the nerves, muscles and tendons. It is this fibrous layer (palmar fascia) which is affected in Dupuytren's disease. Generally it starts off with a thickening or a nodule in the palm, most frequently in the line of the ring finger. It may progress to produce a contracture, similar to that in the picture.

No treatment for Dupuytren's disease is required in the early stages unless the symptoms genuinely demand it. As the condition cannot be cured by surgery, there is no particular rush to operate. In fact in younger patients (under the age of 55 years) there is a real risk that the disease process will recur relatively quickly, sometimes worse than it was initially. I tend to wait until the symptoms (i.e. when the contracture really causes a functional deficit) are sufficiently interfering in someone's lifestyle to perform the surgery.Personally, I have not found that physiotherapy, massage or splintage seems to make a great deal of difference, though these techniques are used in other units.

A new treatment is becoming available in the form of an injection of an enzyme. This is called collagenase and is being marketed in the UK as Xiapex. The injection is performed on one day into the tight abnormal tissue and then on the following day or later the finger is manipulated to snap the tight cord. This straightens out the finger. It has become clearer this year that collagenase injection is effective but there are very specific clinical indications for its use. Also, the five-year results show that the recurrence rate is very similar to that of fasciectomy. I have decided not offer this treatment.

If and when it is appropriate to perform surgery then there a number of options depending upon the severity of the condition. These include the following:

  • Fasciotomy
  • Fasciectomy
  • Dermofasciectomy
  • Amputation