Dupuytren's Disease
Mr Mike Hayton
FRCS(Trauma and Orth) FFSEM (UK)
Consultant Orthopaedic Hand Surgeon
Other common names
Viking's disease
Who does it affect?
Usually males over the age of 40 years, occasionally females.
What is Dupuytren's and why does it occur?
Dupuytren's disease is a thickening of the palmar fascia in the hand and fingers. In lay terms it can be described as a type of canvas that sticks the skin to the deeper structures, giving firmness to the palm and fingers allowing a good grip. This is in contrast to the back of the hand where the skin is mobile and would not provide such rigidity to pick objects if on the palm.
In the palmar fascia there are cells called myofibroblasts. In patients with Dupuytren's disease these cells multiply, proliferate and form nodules and cords like structures in the palm and finger. These eventually contract pulling the finger into the palm.
There are a number of risk factors associated with developing Dupuytren's disease. These include amongst others: genetic (inherited), diabetes, excess alcohol intake, epilepsy and/or its treatment.
In the vast majority of patients we do not know why they develop the disease, but is probably inherited to some extent.
Symptoms
Thickening and cord like structures develop gradually in the palm and extend into the fingers causing the fingers to roll up into the palm. Often they are tender in the early stages but become painless as they mature.
An advanced case is shown in the photograph at the top of the page. Symptoms can arise such as :
- an inability to place the hand flat on a table
- catching your eye with a finger when washing your face
- inability to get a hand in pocket
- problems shaking hands
Clinical Examination
The disease is usually very easy to diagnose and has a very characteristic appearance. Nodules and cord like structures develop in the palm and may extend down onto the front of the finger. As the disease progresses the fingers may curl over into the palm.
A simple test to try and evaluate the severity of the disease is the "table top test". The patient is asked to place the hand flat on the table. If they are unable to do so then it is likely that disease may need intervention.
Investigations
None are usually required as the condition is very easy to diagnose.
Non-operative treatment
Percutaneous needle fasciotomy (PNF)
This is a procedure that is performed under local anaesthetic in an ambulatory type setting. Once numb with a local anaesthic injection in the skin over the cord, the surgeon uses a small needle to incise and release the cords through a few tiny needle holes. Sometimes after correction the skin stretches and the holes can be a few mm's that heal then over a few weeks. It is generally thought to me a more rapid recovery although the recurrence rates are higher. In my practice it is usually for those people who have very well defined cords in the palm. Thicker cords, and cords in the finger are more difficult to perform PNF.
Collagenase (Xiapex) enzyme injections
Unfortunately Xiapex has been removed from clinical use, on commercial grounds, by the manufacturer and is unavailable for Dupuytren's disease. This is very disappointing as it was proving to be very useful and effective.
Radiotherapy
Radiotherapy has been used for may years to that Dupuytren's disease. It is particularly common in Europe. The treatment is only indicated for early disease in the palm with no flexion contracture of the fingers. Treatment consists of daily radiotherapy for 5 days followed by a 5 week break and then daily treatment again for 5 days. The risks associated with radiotherapy are redness and dryness of the palms and a theoretical risk of causing a malignancy, although no cases have ever been reported. The room is quite large for the machine but totally painless.
The hand is kept still and in the same place for each treatment by a mould as shown below.
Operative treatment
The most common treatment for symptomatic Dupuytrens disease is surgery.
Surgery is performed as a day case procedure under local, regional or general anaesthetic. The surgery takes between 30 and 90 minutes depending upon how severe the contracture has become. A forearm rubber band tourniquet is increasingly usually used when the surgery is performed wide awake with local anaesthetic. This type of torniquet is much better tolerated than a traditional above elbow pneumatic torniquet.
The surgery is performed through a longitudinal or zigzag type incision in the palm and along the finger. The skin flaps are elevated and great care is taken not to injure nerves and blood vessels to the finger. The Dupuytren's diseased cord is removed. Occasionally, in more advanced cases when the skin is heavily involved a skin graft needs to be placed over the wound. The skin graft is taken from the forearm or groin (for larger grafts). The tourniquet, if used, is then released and any bleeding controlled. The skin is sutured with absorbable stitches and a bulky dressing is applied with a plaster of Paris slab for immobilisation.
In all my cases the skin sutures are dissolvable and avoids the painstaking and uncomfortable removal of the tiny stitches that are inserted.
For those who wish to self pay we have a very efficient walk in walk out surgery facility at very competitive rates. Please contact info@mikehayton.com and consider sending a few photos to try and help give an idea as to options.
Post-operative rehabilitation
The local anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. My preference is to remove the dressing between 3 and 5 days, the wound is cleaned and redressed with a simple dressing and kept covered for 7-10 days and early motion is encouraged.The skin stitches are usually dissolvable and dissolve over a 2 to 4 week period. The hand therapist will make a resting night-time thermoplastic splint that should be used at night for 6 months.
Click here to download a pdf on post operative instructions
Return to activities of daily living
It is my advice to keep the wound covered, clean and dry for about 10 days.
Return to driving:
The hand needs to have full control of the steering wheel in case of emergency. Return to safe control of a vehicle varies between individuals but often patients can drive within the first week if they feel safe to do so..
Return to work:
Everyone has different work environments.
Early desk based activities may resume immediately but returning to heavy manual labour should be prevented for approximately 4 - 6 weeks until the wound is fully healed and stable. Please ask your surgeon for advice on this.
Complications
Overall more than 95% of patients are happy with the result. However complications can occur.
There are complications specific to Dupuytren's surgery and also general complications associated with hand surgery.
Please look at my general hand complications page by clicking here but also see below for some specific complications
Specific complications:
Recurrence: the disease will always recur, however, most patients have a long lasting result that they are happy with.
Failure to completely straighten the finger (particularly after the 2nd and 3rd time surgery or advanced disease).
Injury to the blood vessels and nerves to the finger (very much less than 1%) may leave one side of the finger numb. If this occurs the wound should be explored and if injured, the nerve repaired. There is an extremely tiny risk of digit loss with Dupuytren surgery requiring amputation either on table or post operatively and is usually a result of past blood vessel compromise in revision surgery for very advanced disease.
There is a very small risk of the skin graft, if used, not healing requiring revsion surgery.
Useful links with more information
British Dupuytren's society click here or a European site click www.dupuytren-online.info
Hear a BBC Radio 4 interview with Mike Hayton and Dr Mark Porter on Dupuytren's disease, click on the icon below
