Dupuytren’s Contracture

Dupuytren’s Contracture

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 to divide the cord with a needle (needle fasciotomy), which can be done under local anaesthetic. It works best for a relatively mild contracture with the cord prominent in the palm causing the first knuckle (metacarpophalangeal joint) to be bent. Following the procedure the hand has a dressing on it for a day or two, and some patients will be referred to a hand therapist to be made a splint to wear at night for a few weeks. With this treatment the contracture tends to recur more rapidly than after an operation, which is the alternative treatment. The risks are tearing of the skin, failure to fully straighten the finger, recurrence of the contracture and there is a small risk of an injury to the nerves or tendons.

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.

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