Dupuytren’s contracture

Dupuytren contracture is a disease that affects the structures located under the palmar skin, causing, over many years, the retraction of the fingers in the palm.

An obvious cause has not been discovered, there is only a predisposition to this disease caused by:

  • Age – most commonly in people older than 50
  • More common in men
  • Northern ancestors or family history of Dupuytren
  • Alcoholism and smoking – which cause microvascular modifications
  • Long-term treatment with barbiturates
  • Diabetes (due to microangiopathy)
  • Intense manual labor
  • NSAID medication (as in rheumatoid arthritis)
  • Combination with other fibromatoses: Peyronie’s disease, Ledderhose disease (plantar fibromatosis), knuckle-pads (dorsal digital cushions).

Dupuytren’s contracture is usually bilateral, and not associated with the dominant hand.

Excessive production of embryonic collagen at the palmar and digital level, due to insufficient oxygen supply at this level (see one of the causes).

Symptoms

  • longitudinal cords along the digital rays, initially occurring on the palm and later on the fingers. Usually the skin adheres to the braces only in the area of ​​the distal palmar crease. They can go longitudinally, forming the center contracture, or they can go obliquely on the sides of the finger.
  • Generally, the digital cords end distally from the proximal, central and / or lateral interphalangeal joint. Sometimes there is a large nodule above the digital cord.
  • The most often affected fingers are the ring and the little finger. Very rarely the middle finger and the index.
  • Unable to extend the finger, having it permanently flexed.
  • Slow progression that takes years.
  • Nodules, skin depressions and deformations of the palmar crease. The nodules are subcutaneous, painless, firm tissue masses, located along the path of the longitudinal cords of the palmar fascia, along the digital rays. Nodules may also appear on the volar plate of the fingers, especially at the level of the proximal phalanx and digital crease.
  • Initially, there’s a thickening of the palmar tegument, as the contracture progresses, the tegument creases.
  • It forms firm nodules in the palm, which can be sensitive to touch. But in most cases, they are painless.
  • In advanced stages, fibrous strings form under the skin that extend from the palm to the fingers.
  • As it progresses, it hinders the functions of the hand (grasping an object, dressing, washing one’s face, shaking hands, etc.).

Evolution without treatment:

  • Loss of hand use
  • maceration of the palmar skin, infection
  • digital amputation
  • affects the vascular pedicles, digital anesthesia and trophic disorders
  • Dupuytren’s disease does not have a continuous progression, but evolves in leaps, with alternating active and inactive periods, the duration of which varies from patient to patient.
  • the average duration of Dupuytren’s disease evolution is about 4-5 years, after which the lesions stabilize, fixing the fingers in flexion and thus limiting the functionality of the hand

Non-surgical treatment:

  • splints,
  • radiation
  • dimethyl sulfoxide,
  • creams with vitamin E,
  • anti-gout medication,
  • physiotherapy,
  • ultrasound
  • Percutaneous enzymatic fasciotomy
  • Percutaneous fasciotomy (Advantages: fast procedure, rapid recovery. Disadvantages: high recurrence, risk of damage of digital and common vascular-nerve pedicles, incomplete release of strings)

Surgical treatment

The only therapeutic solution that can lead to very good results in Dupuytren’s disease.

Incisions are made to excise the fibrotic tissue that makes up the contracture.

Inspection of vascular pedicles – if the collateral digital nerves are trapped in the fibrosis, external neurolysis (external cleaning of the nerve) is performed. If the scar tissue cannot be removed from the nerve and if determined that long-term evolution will lead to digital anesthesia / hypoesthesia, excision of the nerve fragment and neuroraphobia (nerve suture) will be performed.

After a long-term evolution or when there is a very tight articular contracture, the joint cannot be completely extended, even after an extensive aponeurotomy, there for a surgery that addresses the affected periarticular structures is required. If the joint is corrected to less than 30 degrees in flexion, it is considered an acceptable reduction, and immobilization and postoperative physiotherapy will maintain this condition, so an arthroplasty (or arthrodesis) is not recommended.

A flexion contracture of more than 30 degrees will be distressing for the patients and one or more methods of finger relaxation will be required:

  • attempt passive extension of the finger
  • incision of the flexor sheath. Often, the shortening of the fibrous sheath of the flexors is the only reason the finger in still flexed. The movable portion between the pulleys A2 and A4 contract and shorten, contributing to the deformation in flexion. The excision of a section of the movable part of the tendon is recommended. If we are not successful with this procedure, then the following will occur
  • excising the attachment of accessory collateral ligaments to the volar plate. With this maneuver we often get the full passive extension of the finger.
  • alternatively, we can also cut the proximal ligaments of the volar plate to the skeleton, but the gain is quite small.

If either of these methods fails to achieve full extension, it is best to accept the contracture and hope that postoperative recovery will reduce it or maintain its current level. The risk of extension joints is much higher; that is why it is better to maintain a degree of flexion, than to obtain an extension stiffness, which is much more impairing.

The suture of the tegument will be made by means of V-Y advancement flaps or the cutting of the remaining tegument in Z-plasty. If the skin is insufficient, it will require:

  • full-thickness skin grafts,
  • rotating flaps raised from the posterior side of the finger, and covering the donor area with a full thickness skin graft.
  • closure through spontaneous healing without suture
  • Separate wires, which will be removed at 14 days.


Postoperative complications:

  • limited flexion of the proximal interphalangeal joint (the most common complication – 6% of cases)
  • Necrosis of flaps
  • Necrosis of wound edges
  • hematoma
  • Infection
  • Dehiscence
  • Edema
  • Injury of the digital or common vasculoskeletal pedicle
  • Neuroma after neuropathy
  • Regional pain syndrome (sympathetic reflex dystrophy), which can happen after any lesion in the upper limb
  • Hypertrophic / keloid scar

Postoperative recommendations:

  • A cast will be placed on the dorsal side of the hand and forearm, immobilizing the extended fist, with the metacarpophalangeal joint in slight flexion (10-30 degrees) and extended interphalangeal joints (when possible).
  • Keep the arm elevated for at least 48 hours.
  • Edema management (elevated position, cold local packs in the first 48 hours, NSAIDs).
  • The dressing will be checked at 24-48 hours postoperatively.
  • Early mobilization after the inflammatory phase (day 0-4) as sutured incisions can tolerate movements
  • Removal of the suture material after 14 days
  • Pain management
  • Scar management
  • Wash with soap and water after suture material removal
  • Physical therapy – MANDATORY