What is dupuytrens contracture?
It is disease of the fibrous structure that holds the skin of the palm in place allowing us having firm grip on objects. In this condition patient develops either pits or firm to hard nodules over the palm. Over a period varying from months to years, this cord begins to shrink and so to draw the finger inexorably into a clawed position. This is the contracture, and as it progresses so does the nuisance and disability associated with it.
Does the disease spread?
This disease may begin to affect adjacent fingers or fingers on the opposite hand.
Can surgery correct the problem?
At early stage surgery can correct the contracture, particularly if it has afflicted the knuckle joints at the junction of palm and finger (metacarpophalangeal joints: MCPJ). If the middle joint (proximal interphalangeal joint: PIPJ) of the finger is affected, correction is more complex and delay incurs more of a penalty in terms of less than full correction. It is for this reason that surgeons like to have the opportunity to examine the hand at an early stage of the disease, and as a general rule, if you are no longer able to place the hand palm down flat to the table with the entire palm in contact with the table-top, then you should seek advice.
Why does it happen?
There are some factors influencing the appearance and progress of dupuytren’s disease like alcohol consumption, age, family history. Sometimes dupuytren’s contracture may be provoked by a single injury or patients recalls that it has started since that injury. The exact cause and how does it progresses is unknown.
When is ideal time for treatment?
The presentation and progression can vary greatly among individuals. In some the progress is very slow while in others it may rapidly progress to affect adjacent digits. Younger the patient the faster it progresses. Also correction is more difficult in gross deformities. So it is better to get it treated early.
What are the treatment options?
Medicines are not effective in treating this condition. Splinting, steroid injections and other methods have been tried unsuccessfully in the past. Surgery is the only effective form of treatment.
What kind of surgery will help me getting it cured?
The extent of surgery depends upon the severity disease. In mild disease through a zig-zag incision in the palm and digit the diseased palmar fascia can be approached and excised. The finger can be completely straightened. These cases need minimum splinting and after a week or two patients will be allowed to use their hands for all the activities.
In more severe cases the skin itself is involved in the disease process and has to be removed. These are the cases where the diseased skin has to be removed and the resultant raw area is covered with skin graft. These patients need splinting for longer period of time. Secondly skin grafting has a tendency of contracting on its own and splint is needed to resist the same. Though once the skin graft settles, the recurrence under a skin graft is almost unknown.
One of the complex problems with dupuytren’s contracture is its recurrence. In the affected or disease prone person the disease tends to recur in the adjacent digits. Skin grafting to some extent has solved that problem it least in the involved fingers. Whether a skin graft is necessary or not will be discussed with you.
Do I need physiotherapy following the operation?
Yes, the exercises start once the wound healing is complete. Roughly after 2 weeks after the surgery. The aim of exercises is to make the finger as straight as possible. Many patients benefit from physiotherapy advice.
With time the scars become more soft and supple. Hand gradually regains its full mobility. In selected patients we prefer continuing the splint especially during night for longer period of time.
How long will I have to be in the hospital?
Normally the surgery can be performed under regional anaesthesia only for the involved limb. If the patient prefers a general anaesthesia can be arranged. Admission and discharge within 24 hours is commonly followed (overnight stay in the hospital).
How are the results?
Surgery for dupuytren’s disease is reliable and predictable by and large. Few complications that can happen like in any wound are a small risk of bleeding or infection, but this is rare. Skin grafts if necessary have poor healing on occasions and may need minor revisions. Injury to one of the small nerves of the hand though very uncommon in expert hands is a possibility as they are badly involved in the scar tissue.
A more serious complication of surgery is an unpredictable and poorly understood condition called reflex sympathetic dystrophy in which the hand swells, becomes red, and may develop a burning type of pain. This is fortunately very rare in Indian population, but may lead to prolonged stiffness of hand.
Lastly complete correction of long standing joint contracture or recurrent disease is sometimes not possible.
As discussed earlier recurrence is very common and the only solution to this problem is early reporting and early treatment of the problem.