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. I refer to it in lay mans terms 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 Dupuytren's disease these cells multiply, proliferate and eventually contract. They form nodules and cords like structures in the palm and finger that gradually pull the fingers over 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. An advanced case is shown in the photograph at the top of the page.  In the initial stages the nodules can be tender but the pain usually settles. 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,
  • - and 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 surgery in the future.

 

 

Investigations

None are usually required as the condition is very easy to diagnose.

Non-operative treatment

Percutaneous needle fasciotomy

This is an outpatient procedure that is performed under local anaesthetic. Once numb the surgeon uses a small needle to cut the diseased cords through a tiny needle hole. I performed this procedure many years ago but largely abandoned it due to a high recurrence rate. It does however have its place and some surgeons use this as a first line treatment.

Collagenase enzyme injections 

In 2012,  a new enzyme injection, called Xiapex was released in the UK to dissolve the Dupuytrens disease. I have been using Xiapex since its UK launch and was the first UK surgeon to use Xiapex outside clinical trials.  remains very pleased with the results. It is performed in the outpatient department. On day 1 the Xiapex enzyme is injected into the Dupuytren disease. In the next few days to suit, the patient returns to the out patient department and, under local anaesthetic, the finger is manipulated straight. The enzyme will have dissolved the Dupuytren disease in that area allowing the finger to become straight.

for more info on Xiapex CLICK HERE

Radiotherapy

Radiotherapy has been used for may years to that Dupuytren's disease. It is particularly common in Germany. 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 surgery is performed as a day case procedure under local or general anaesthetic. The surgery takes between 30 and 60 minutes depending upon how severe the condition has become. A tourniquet is not usually used if the procedure is performed wide awake with local anaesthetic.

The surgery is performed through a 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 disease removed. Occasionally in more advanced cases a skin graft needs to be placed over the wound. The skin 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.

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 2 and 3 days. The wound is cleaned and redressed with a simple dressing and kept covered for 7-10 days. Early motion is encouraged.The skin stitches are usually dissolvable and dissolve over a 2 to 4 week period. The therapist will apply a resting night-time 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.

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. 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.

General complications:

 - Infection (Less than 1%)

This is usually very minor and resolves with a short course of antibiotics.

 - Numbness

This may occur if the nerve is injured during the operation. Great care is taken during the procedure to identify the nerves and protect them at all times. The risk of nerve injury is much less than 1% in my practice. If the nerve is injured during the procedure and identified at the time it will be repaired.

- Neuroma (Less than 1%, a coiled painful nerve bundle)

If is nerve is injured during the operation (<1%), the end of the nerve can sometimes overgrow into a painful bundle. 


Chronic regional pain syndrome (1-2% rare reaction to surgery with painful stiff hands- this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

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.

The skin graft, if used, not healing.

 

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

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