DUPUYTREN CONTRACTURE
Dupuytren contracture is a progressive thickening and
contracture of the palmar aponeurosis (fascia) that results in flexion
deformities of the finger joints. Although its cause is unknown, trauma is not
a factor in its origin (but can accelerate progression) and an increased
familial incidence suggests a genetic component. Dupuytren contracture chiefly
affects middle-aged white men, particularly those of northern European descent.
It most commonly affects the ring and small fingers, followed infrequently by
long finger involvement. It rarely affects the index finger or the thumb.
CLINICAL MANIFESTATIONS
The first sign of the condition is a slowly enlarging,
firm, and slightly painful nodule that appears under the skin near the distal
palmar crease opposite the ring finger; other nodules may form at the bases of
the ring and small fingers. Subcutaneous contracting cords develop later; they
extend proximally from the nodule toward the base of the palm and distally into
the proximal segment of a finger.
Flexion contractures gradually develop in the meta-carpophalangeal
joint and later in the proximal inter- phalangeal joint of the involved finger.
The degree of the flexion deformities and their development rate vary, depending
on the extent of thickening and contracture in the palmar fascia. Some
contractures develop quickly over a few weeks or months; others take several
years. Long remissions may occur, only to be followed by exacerbations and
increasing deformity. As the flexion deformity progresses, secondary
contractures occur in the skin, nerves, blood vessels, and joint capsules. Because there is no
tendon involvement, active flexion of the fingers remains complete. Involvement
is usually bilateral; and in 5% of patients, similar contractures occur in the
feet.
Serious changes occur in the skin overlying the involved
fascia. The short fascial fibers that extend from the palmar aponeurosis to the
skin contract and draw folds of skin inward, producing dimpling, pitting, fissuring, and puckering. The subcutaneous fat atrophies,
and the skin becomes thickened, less mobile, and attached firmly to the
underlying involved fascia. These changes occur particularly in the region of
the distal palmar crease on the ulnar side of the palm. Except for the nodules,
cords, and finger contractures, the patient has few complaints. Developing
nodules may be slightly painful and tender. Finger deformities interfere with
use of the hand, leading to disability in patients with certain
occupations. The stages are not distinct and description of them is not essential.
TREATMENT
Surgery is the only effective treatment and should be
done before the skin has deteriorated and the skin, nerves, and joint capsules
have become too contracted. A typical timing for surgery is when the patient
can no longer lay the hand flat on the table and definitely when contracture
occurs at the proximal interphalangeal joint. Surgical repair should not be
performed before contractures develop.
Partial fasciectomy, the most common treatment,
removes all of the thickened and contracted aponeurosis without excision of the
uninvolved portion. During fasciectomy, tourniquet hemostasis is essential
because hematoma is the most common complication. Skin flaps must be reflected
very carefully to avoid buttonholing of the skin and necrosis and the
subsequent need for skin grafts. However, an open palm technique has been
successfully utilized by making a distal palmar trans- verse crease; and after
full extension is obtained, the wound edges gap open often more than 2 cm. This
can be treated with dressing changes, and it typically heals over time by wound
contracture and epithelialization. In addition, great care must be taken to
avoid any damage to the nerves and blood vessels that may be surrounded and
distorted by the hypertrophic fibrous tissue. Neurovascular bundles are at
times drawn across the midline of the finger, making them difficult to identify
and easy to injure. Resection of Dupuytren contractures requires a keen
knowledge of anatomy and surgical exposures to avoid neurovascular injury.
After surgery, the fingers are not initially splinted
as was done in the past because this avoids overstretching the neurovascular
bundles, which can lead to neurapraxia, followed by a dystrophic response and
complex regional pain syndrome. After 5 to 7 days, splinting is initiated and
splints are adjusted weekly to bring the fingers gradually into the corrected
extended position. Prolonged postoperative care, which may require several
months, is necessary to obtain optimal results and includes splinting the hand in the flat position between exercise
sessions.
Percutaneous fasciotomy is reserved for poor-risk,
elderly persons or as a preliminary procedure to fasciectomy in patients who
have marked contractures; tight, adherent skin; and shortening of nerves and
joint capsules. The results are better when this procedure is done in the
residual stage of the contracture rather than during active progression of the disease.
