Treatment is only recommended when a contracture has developed such that the palm cannot be placed flat on a surface, and the joint cannot be straightened beyond 30 degrees of flexion. The treatment options are an injection of an enzyme (brand name Xiapex) into the cord of Dupuytren’s followed by a manipulation under local anaesthetic a day or two later. For suitable patients the cord is injected with a small volume of Xiapex. The hand is bandaged and the patient advised not to use it. The hand can swell, bruise and be quite sore. 24-48 hours later the patient returns to the hospital, the palm is injected with local anaesthetic and the finger then gently manipulated to straighten it. The hand is bandaged again for 24 hours after which the patient is encouraged to move the fingers and use the hand as they find comfortable. It will initially be bruised and sore, settling after a few days. Patients are referred to see a hand therapist following the manipulation for exercises and a splint which is worn at night for 3 months.
Other treatments are the cord can be divided with a needle inserted through the skin or surgery.
The surgical procedure is called a palmar fasciectomy – removal of the diseased fascia, is performed. It involves separating the skin from the underlying lumps and cords of Dupuytren’s tissue, isolating and protecting the nerves and arteries that supply the fingertips and then removing the affected tissue. See photographs below.#
Surgery is usually carried out as a daycase under a general anaesthetic or a regional block where the patient is awake but the arm completely numb. A zigzag incision is made from the palm extending into the finger.
Younger patients with very aggressive disease may need a skin graft because they have skin involvement, which requires removal of the overlying skin at the base of the finger. The skin graft is usually taken from the inner forearm. This technique is also used for patients who have a recurrent contracture after previous surgery.
Patients leave theatre with a plaster of Paris splint beneath heavy bandages to allow the fingers to be kept straight and also to allow the graft, if needed, the best possible chance of taking.
Postoperative physiotherapy and splintage requiring the skills of a Hand Therapist are vital for the success of this operation and a few days after the procedure, you will have an appointment for the removal of the bandages and a splint will be made for the fingers, to be worn at night for up to three months. This will stop the fingers from flexing into the palm during the night.
At two weeks post-op the stitches will be removed. It is vital at this stage that patients work hard at keeping their fingers moving, particularly bending and flexing. Sometimes the wound is not fully healed at this stage and needs dressings for a bit longer.
Twenty per cent of patients will have temporary finger numbness following surgery but there is only a one in 100 chance that this will be permanent. Some patients have problems after surgery with stiffness, swelling and pain and they may need prolonged therapy and treatment, in some cases in a Pain Clinic. The condition can recur. There is a small risk of wound infection.
Nevertheless, this is a worthwhile and rewarding surgery and it can prevent patients from progressing to a condition of disabling contracture.