Dupuytren’s contracture

Dupuytren’s contracture

Introduction
Dupuytren’s contracture is a thickening of deep tissue (fascia), which passes from the palm into the fingers. Shortening of this tissue causes “bands” which pull the fingers into the palm. The cause of this is unknown but it tends to run in families and may indicate that you have Celtic ancestry. The condition is progressive and the only treatment is surgery. If untreated, the fingers will be gradually pulled into the palm.

Fasciectomy
Your Dupuytren’s contracture will be corrected by removal of the abnormal fascia and relaxation of the overlying skin. The entire wound is stitched up in a zigzag manner, which lengthens it but occasionally, a segment of the wound in the palm is not stitched, being left open to heal by itself (open-palm technique).

Dermofasciectomy
In some situations it is necessary to also remove the overlying skin if it is affected by the disease or previous operation.

Needle Aponeurotomy (NA)
Needle aponeurotomy or percutaneous needle fasciotomy (PNF) is a minimally invasive technique that originally became popular in France more than 20 years ago. The aim of NA is to make bent fingers functional again by straightening them and achieve minimal side effects. The technique uses needles to puncture the contracting (blocking) Dupuytren cord and thus weaken it until it can be broken by mechanical force, typically with a characteristic snap. NA is a non-surgical, ambulant, outpatient procedure. It is important that you recognize that not all cases of Dupuytren's disease is treatable by needle aponeurotomy. It is most appropriate for simple cords that are well-defined in the palm with soft, mobile overlying skin. It is least appropriate for extensive disease, contracted skin, contracted finger joints, and cords that are over the metacarpal-phalangeal joint (the "knuckle" of the hand).

Amputation
Very rare in unoperated cases but may be preferred in a finger in which the bands have returned many times and where there has been previous nerve and vessel damage.

Post-Operative Care

 Your hand is frozen for the operation local anaesthetic is also injected around the cut at the end of the operation. This area and possibly some of the fingers will remain numb for up to ten hours after surgery. As this effect wears off, it may be worth taking some painkillers.

 Hand elevation is important to prevent swelling and stiffness of the fingers. Raise your hand and arm above your heart. Remember not to walk with your hand dangling, or to sit with your hand held in your lap.

 You will be initially placed in a bulky dressing consisting of gauze, plaster of paris and bandage to rest the hand. The dressing will be removed after 3-5 days and then be left open at this stage, if possible, to allow mobilization of the fingers. The open-palm technique usually requires dressing to be applied to the palm for 2-3 weeks while mobilization is performed in the usual way.

 At this time, you will see a hand therapist who will fit you with a splint and give you specific exercises to perform. The splint is to be worn at night for 6-12 weeks to keep the finger straight. During the day, the hand should be exercised and you should perform normal light activities. You may require ongoing therapy for range of motion and strengthening.

 Your stitches will be removed one to two weeks after the operation. Following this the scar will be somewhat firm to touch and tender. This can be helped by firmly massaging the area with fragrance free moisturizing cream. At this stage it is safe to get the hand wet in the bath or shower. The scar and the surrounding skin often become very dry and will be more comfortable if a moisturizer is applied, including the scar itself. Your therapist may give you a scar pad to help the scar to soften and flatten.

 It is often not possible to fully straighten fingers that are very bent at the time of the operation, particularly if much of the bend occurs in the middle joint of the finger. This can sometimes be improved with splinting and exercise later after the operation. Duputren’s contracture can return either at the site of surgery or else where in the hand.

 You can usually drive a car after two weeks as long as you are comfortable and have regained good finger movements. Timing of your return to work is variable according to your occupation and this should be discussed.

Please call our office or your family doctor if:

 The prescribed medication does not provide adequate pain relief
 The dressing/cast is too tight or uncomfortable
 Numbness persists
 You have a fever
 There is s smelly, yellow (or green) discharge and your hand is hot and swollen

Risks of Surgery

Nerve Damage
The nerves running to the fingers can be damaged during the surgery and cause numbness in part of the finger. This complication is unusual in unoperated areas but becomes more common during repeat operations. If this occurs the nerve would be repaired immediately, if possible.

Infection
Any operation can be followed by redness and tenderness, which may indicate infection. Do not apply antiseptics. You should see your doctor about this and antibiotics may be prescribed.

Bleeding
This can cause a collection of blood under the stitches, which is painful and which can cause problems with the wound. This is usually managed by removing some of the stitches but occasionally it is necessary to return to the operating theatre to stop bleeding. Tell the surgeon if you are on blood thinners or aspirin.

Stiffness
About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation. This problem cannot be predicted but will be watched for afterwards and treated with hand therapy.

Finger Loss
This is extremely rare but can occur in fingers that have had many operations before and in patients who have diseases of blood vessels such as diabetes or scleroderma.