Dupuytren's Disease

What is it?

Dupuytren’s disease is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm) (See Figure 1). It often starts with firm lumps in the palm that adhere to the underside of the skin. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers with the ring and little fingers most commonly affected. Gradually, these cords may cause the fingers to bend into the palm (See Figure 2).These cords may be mistaken for tendons, but they actually lie between the skin and the tendons (See Figure 3). Although the skin may become involved in the process, the deeper structures —such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

What Causes It?

The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia.The problem is more common in men over age 40 and in people of northern European descent. It often runs in families and usually involves both hands.

What are the symptoms and signs?

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop. As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords, while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

What are the treatment options?

Patients who have nodules in their palms, but do not have any contracture of the fingers, do not require surgical treatment. Nodules usually do not cause pain and it is generally best to leave these alone without treatment.

If the fingers have started to contract, then surgical treatment to remove the Dupuytren’s disease and release the contracted joints is the best option.The goal of surgery is to release the contracture and restore hand function. Excellent results can be obtained from this treatment. However if treatment is delayed until the contractures are severe, the results are generally not as good. Surgical treatment to release contractures in the fingers generally involves creating skin flaps that need to be rotated into position to provide coverage. Occasionally, skin grafts will be necessary as well. In the palm, surgical releases are often treated by leaving the palm wound open and allowing this to heal over a period of two to four weeks. Because Dupuytren’s surgery requires removal of the contracted layer from both the overlying skin as well as from the underlying deep tissues, there is substantial dissection involved with the surgery.Therefore it is common to have swelling and stiffness. The nerves that provide feeling to the fingertips are often intertwined with the cords. It is common to have some numbness in the affected fingers after surgery.This usually resolves in two to six weeks.

All patients who undergo surgical treatment of Dupuytren’s disease require postoperative therapy.This generally includes splinting of the wrist and hand in extension at night for one to two months, as well as aggressive therapy to regain full range of motion. Long term results are quite good as long as aggressive therapy is provided.

Dupuytren’s disease can recur after surgery, and in more severe cases full release of the contractures is sometimes not possible. Patients often have transient numbness in the fingers after the surgery because of stretching of the nerves, which have contracted as well.