Dupuytren's contracture

Dupuytren's contracture is a common hand condition seen in Europe, so much so that the Vikings have been blamed for it as there is a strong familial tendency. The palm of the hand is much tougher than other parts of the arm and this is due to an extra layer of tough fibrous (scar-like) tissue just under the skin and above the nerves, muscles and tendons. It is this fibrous layer (palmar fascia) which is affected in Dupuytren's disease. Generally it starts off with a thickening or a nodule in the palm, most frequently in the line of the ring finger. It may progress to produce a contracture, similar to that in the picture.

Dupuytrens

No treatment for Dupuytren's disease is required in the early stages unless the symptoms genuinely demand it. As the condition cannot be cured by surgery, there is no particular rush to operate. In fact in younger patients (under the age of 55 years) there is a real risk that the disease process will recur relatively quickly, sometimes worse than it was initially. I tend to wait until the symptoms (i.e. when the contracture really causes a functional deficit) are sufficiently interfering in someone's lifestyle to perform the surgery. Personally, I have not found that physiotherapy, massage or splintage seems to make a great deal of difference, though these techniques are used in other units.

A new treatment is becoming available in the form of an injection of an enzyme. This is called collagenase and is being marketed in the UK as Xiapex. It is a potentially dangerous agent if injected into the wrong area so the clinician requires training to administer it. It is gradually being introduced into this country. The injection is performed on one day into the tight abnormal tissue and then on the following day the fingers are manipulated to snap the tight cord. This straightens the fingers out. From my personal perspective I have some concerns with the treatment. There are always risks and complications with all treatments and it looks as if the risks from collagenase are about the same as surgery so there may not be such a huge benefit. What I am not sure about yet is whether the injection treatment genuinely slows the progression of the disease. If it does then it will be fantastic but if not then it may be more difficult to operate through the tissue that has been injected. I will await the longer term results with interest.

Surgical options include the following: