Dupuytren’s contracture surgery

Palmar fasciectomy is a surgical procedure to treat Dupuytren’s contracture. During the intervention, the contraction of the palmar fascia is released or removed, depending on the stage of the lesion. Surgery corrects the thickening of the skin in the palm of the hand or on a finger. It also straightens the fingers which have been pulled towards the palm of the hand. Sometimes both hands need to be treated.

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What is Dupuytren’s contracture?

Dupuytren’s contracture, also known as Viking disease or contraction of the palmar fascia, is a disease of the layer of tissue that lies beneath the skin of the palm of the hand. It causes abnormal thickening and contraction of the fibrous connective tissues of the palm, causing the fingers to bend inwards and often preventing them from functioning properly.

Rarely, the condition can affect other parts of the body: it can manifest itself in the form of lumps on the back of the finger joints (Garrod’s pads), lumps in the arch of the feet (Ledderhose disease), or beneath the skin of the penis.

What causes Dupuytren’s contracture?

The exact cause of Dupuytren’s contracture is unknown. However, some risk factors have been identified. Genetic predisposition seems to play a role in the development of the condition, as Dupuytren’s tends to run in some families. It is most common in men above 50, but it does affect women too. Northern European ancestry is also a risk factor, some hypothesise that the prevalence of the deformity in certain areas could be explained Viking migration. Dupuytren’s contracture is commonly referred to as „Viking disease”.

Dupuytren’s contracture forms due to the benign tumor of the palmar fascia. The contracture first presents as a thickening or nodule in the palm, which is usually painless. After a while, these nodules form a thick cord which in later stages starts to gradually contract the finger(s) inwards towards the palm. In most cases finger the ring finger is affected, followed by the little finger, and sometimes the middle finger. Often both hands are affected, but the contracture is usually more advanced on the dominant hand.

There is evidence that Dupuytren’s contracture is more likely to develop in people with diabetes, smokers, drinkers, patients with epilepsy and those who have previosly suffered trauma tot he hand. The disease is progressive, without treatment it gets gradually worse until the patient is no longer able to use the affected fingers at all.

What are the symptoms of Dupuytren’s contracture?

Dupuytren’s contracture has different symptoms at each stage. The condition usually begins as a thickening of the skin on the palm. As it progresses, the skin can appear puckered or dimpled. A firm lump of tissue may develop which may be sensitive to the touch but usually not painful.

At the next stage, cord-like lumps of tissue form under the skin of the palm which can extend up to the fingers. As these cords gradually tighten, the range of movement of the fingers becomes more and more limited. Most patients visit an orthopedic specialist at this stage. In more advanced stages of the disease, the fingers might be pulled inwards towards the palm. In some cases the fingers stop moving altogether.

Dupuytren’s contracture develops slowly, over several years, but it is difficult to predict how the condition will progress. Some people have only small lumps or cords while others go on to develop severely bent fingers.

Dupuytren's contracture physical examination

How is Dupuytren’s contracture diagnosed?

A physical examination is sufficient to diagnose Dupuytren’s contracture, no additional tests are needed.

How is Dupuytren’s contracture treated?

The treatment of Dupuytren’s contracture depends on the stage of the condition.

At an early stage, if the hand function is good and the lumps aren’t causing any pain or inconvenience, observation is enough.

Steroid injections may help reduce the inflammation. If the cords are already formed, but the movement of the fingers is not significantly limited, physiotherapy can help slow the progression of the contracture fingers.

If you have difficulty using your fingers, fasciectomy is recommended.

When is surgery recommended?

Dupuytren’s contracture is a progressive disease. This means that the condition gets gradually worse and this process cannot be reversed by conservative treatment such as rest or medication. If the complaints have a significant impact on the patient’s ability to carry out their daily activities, the movement of the fingers is limited or the contracture is in an advanced stage and the fingers are completely bent towards the palm, surgical intervention is recommended.

The goal of the surgery is to improve the mobility and function of the fingers. However, it may not always be possible to restore them entirely to their original positio. The outcome of the surgery is closely related to how advanced the disease is when the patient seeks treatment. In the early stages, there is a good chance that hand function can be restored completely. If there is a significant degree of scarring, some loss of function is to be expected.

How is the surgery performed?

Palmar fasciectomy is performed under general, regional or local anesthesia depending on the severity of the contracture. During the intervention, blood flow to the hand is blocked temporarily in order to protect the surrounding nerves and blood vessels. In milder cases, the surgery is performed under local anesthesia. The contracted fibrous tissue is cut with a needle or through a tiny incision.

If the contracture is in an advanced stage, fasciectomy is performed while the patient is under general anesthesia. The surgeon makes Z-shaped incisions on top of the cord, removes the affected connective tissue, and releases the joint capsule. A skin graft is sometimes required to seal the wound.

What are the risks of the operation?

Dupuytren’s contracture surgery is a very safe procedure. However, as with any surgical intervention, there are some risks and possible complications to take into account before making a treatment decision. On rare occasions the surgical site may become infected and the resulting inflammation can spread to the surrounding tissue, potentially affecting tendons, muscles, blood vessels, nerves and bones. In most cases pharmaceutical treatment is sufficient to control the infection, but in severe cases further operation may become necessary.

What to expect after surgery?

Dupuytren’s contracture repair is performed as one-day surgery. After a few hours of monitoring, you will be ready to leave the hospital. However, in case of a severe contracture, where the cords have been removed, 24 hour monitoring is recommended.

The bandage has to be changed on the next day, stitches removal takes place 10 days after surgery. Until then your hand should not come into contact with water.

After cord transcision, normal use of the operated hand can be resumed on the next day.

In severe cases where cords have been removed, the hand should be spared until the wound heals.

In both cases, special hand and finger exercises are recommended for 3-4 weeks after surgery to facilitate recovery.

The wound may remain swollen, sensitive and painful for a few days after surgery. Full recovery takes about 3-4 weeks after cord transcision, and 8-12 weeks after cord removal.