Dupuytren’s to the little finger.

Dupuytren’s to the ring finger

Table top test. Hand unable to flatten fully

Straight finger after Surgery

What is it?
Dupuytren’s contracture is a thickening of deep tissue (fascia), which pass from the palm to the fingers. Shortening of this tissue causes “cords” and “nodules” which pull the finger into the palm. The cause of this is not fully known, but it tends to run in families and may indicate that you have Viking ancestry, as people from Scandinavia have a much higher incidence. The condition is progressive, and if left untreated, the finger contracture can worsen and the results of surgery will not be so successful.

What can be done?
Surgery is the only real treatment once the contracture has reached a certain level. A good test you can do at home is the table top test. If you can place your hand and fingers flat down on a table, then you probably do not require surgery at that time. If however you are unable to lay your hand and fingers flat down, then surgery is most likely to be needed.

There are a number of different surgical options :-

• Fasciectomy – Correction is obtained by removal of the fascia to the affected finger. The wound is stitched up in a zig-zag manner, but occasionally an area is left open to heal by itself (open-palm technique). This is the most common surgical option.
• Fasciotomy – The cord is simply cut via a small incision in the palm or with a hypodermic needle. This can be done under a local anaesthetic, but is only indicated in a proportion of patients.
• Xiapex injections – This is an injection of an enzyme (collagenase) which dissolves part of the Dupuytrens cord. It is a new treatment and not available on the NHS at the present time. It appears to be as effective as a fasciotomy. It is only indicated in certain types of Dupuytrens.
• Dermofasciectomy – In some situations (severe disease, recurrence and younger patients) it is necessary to remove the overlying skin as well as the fascia. This is a more complicated operation as a skin grafthas to be applied to the area.
• Joint Fusion – If the contracture is severe and there is minimal chance of improving it, then the joint affected can be fused (stiffened) in a more functional position.
• Amputation – Done rarely, but can be used if any of the above procedures are not indicated due to severe disease.

Post-operative care
Dupuytren’s surgery is carried out under either a regional or a general anaesthetic. You may be required to stay one night in hospital. After the operation, you will be in a large bandage and it is important to keep the hand elevated (above the level of your heart).
You will be seen by a  Hand Therapist 3-6 days after the surgery, when your dressings will be taken down and a splint applied. They will then start the rehabilitation that is needed. This includes periods of exercises and subsequent periods of resting in the splint. It is vital that you carry out this rehab if you are to have a good result. The splint should be worn at night for up to  4 –6 months after the surgery.
If a skin graft has been applied, your rehabilitation will be somewhat different. Dressings over the graft will be left on for 10 – 14 days.
You will be reviewed in the Orthopaedic clinic at 2 weeks, when the wound will be checked. Usually dissolvable stitches are used. If not, then stitches are removed at this time.

Up to 20% of operations for Dupuytren’s can have a complication. These include:

Infection
Any operation can be followed by infection and this would be treated with antibiotics.

Scar
You will have a scar. This will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with moisturizing cream.

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 (Complex regional pain syndrome). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy.

Nerve
The nerves running to the fingers can be damaged during the surgery and cause numbness in part of the finger.

Recurrence
Dupuytren’s can recur, and some estimate the recurrence rate can be as high as 50% at 10 years, however only a small proportion require further surgery.

Graft Failure
Occasionally if a graft is applied to the area operated on, it does not “take” i.e does not heal to the hand. Rarely further surgery may be required.

Correction
It is often not possible to fully straighten fingers which are very bent at the time of surgery, especially if the bend occurs in the middle joint of the finger (PIP joint). This can sometimes be improved with splinting after the surgery.

Bleeding
Can cause a collection of blood under the stitches which is painful and which can cause a problem 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 the bleeding. Tell the surgeon if you are on anticoagulants or aspirin tablets.

Finger Loss
It is extremely rare, but there is always a very small risk of losing the finger after Dupuytren’s surgery. This would be in severe contractures, where the blood supply is not adequate to keep the finger alive after the finger has been straightened.