What is it ? (Definition)
Dupuytren’s disease (or Dupuytren’s contracture) remains of an unknown exact origin, but both genetics and environmental parameters has been shown to be involved in the genesis of the pathology.
Palmar and digital fascias become retractile and hypertrophic, leading to « chords » contracture under the skin, eventually limiting fingers extension.
Fourth and fifth fingers are the most commonly concerned, and bilateral forms are not rare.
There are palmar forms, in which chords are strictly in the palm, and palmodigital forms, in which the finger itself is also concerned. This distinction is important regarding which relevant therapeutical options are relevant.
How to diagnose it ? (Presentation)
The diagnostic is usually obvious, based on history and physical examination.
Usually, no additional exam is required prior to treatment.
The « Table top test » consists on trying to put the hand flat on top of the table.
If the contracture forbid full contact between the finger and the table, the test is negative, and the hand function usually becomes limited.
What will happen if you do nothing ? (Natural evolution)
Dupuytren’s disease is a benign affection but can be very disabling in daily life.
Spontaneous resolution does not happen.
The functional situation can remain globally unchanged for years, or progressively deteriorate.The evolution of the disease cannot be predicted.
What are the therapeutical options ? (Treatment)
Preoperative physiotherapy occupational therapy and splinting are generally of poor effect.
To date, four treatments exist :
- Simple follow-up :
If the table top test is still positive and the functional limitation is mild, therapeutic abstention is a legitimate option
- Needle Fasciotomy :
In strictly palmar forms, the chord can sometimes be weakened by multiple punctions and then cracked by vigorous extension. This procedure is generally less recommended in digital forms, in which the neurovascular bundle can be displaced by the chord and therefore could be damaged by the needle.
- Hyaluronidase injection :
This treatment consist on injecting a product that chemically destroys the chord.
The injection is carefully made in the chord, and the finger is manipulated to extension the following day. The hand is usually very swollen and painful during several days, and skin lesions may occur following manipulation but all those complication are usually resolutive in a few weeks.
Although encouraging results have been published with this technique, the cases must be strictly selected because it is not appropriated to every form of Dupuytren.
- Surgical fasciectomy :
Surgical removal of the chord (fasciectomy or aponeurectomy) can be made under general or locoregional anesthesia. This surgery has to be made by a specialized hand surgeon, who controls and protect vessels and nerves, therefore limiting the risks of iatrogenic damage.
It is important to understand that the best treatment is a technique or another, but rather a “taylor made” therapeutical program, according to the patient’s needs and will, in concertation with a hand surgeon familial with all of those procedures.
What is the postoperative care ?
Surgery is usually performed in Operating Room (OR) in ambulatory condition.
Needle fasciotomy and hyaluronidase injection can be performed either in OR or in oupatient clinic.
A protective dressing is applied for two weeks after the procedure, then the stitches are removed, massages of the scar are encouraged.
Early active range of motion is usually recommended, but an extension splint is sometimes required to maintain correction.
Patient’s involvement during this phase is of paramount importance for an optimal final result.
What are the reasonable expectations ? (Goals)
– If all goes well :
A return to normal activities is gradually allowed after wound healing.
It usually takes up to several weeks before recovering a normal feeling of the hand, but there is no danger in using it once the healing is complete.
Recurrence rate is estimated around 50% after five years, no matter which technique is used.
– In case of problem :
Surgical fasciectomy may be complicated by hematoma or scar desunion, which delays the healing time but is usually resolutive. This complication is not exceptional especially in heavy smoker, or diabetic patients.
Hyaluronidase injection is usually followed by impressive swelling of the hand, sometimes painful for several days.
All procedures are associated with risk of neurovascular iatrogenic damage, although this risk is rather low. An injured nerve or artery can usually be repaired immediately during an open surgical fasciectomy.
The brutal extension of a finger that has been in flexion contracture for a long period may threaten its vascularization and lead to ischemia.
Some cases of persistant and unexplained postoperative pain has been described.
As in any operation, the theoretical risk of infection exists but this complication remains rare, thanks to the rigor of prevention protocols.
Recurrence has been mentionned above.
Other complications may occur but appears to rare to be mentioned here.
Dr Franck ATLAN