Dupuytren’s disease
Dupuytren's disease is a benign disease of the palmar aponeurosis and most commonly affects the little finger and ring finger. The genetic predisposition and thus the familial accumulation have been proven. Other causes such as diabetes mellitus, accidents, anti-epileptic drugs or liver damage can also cause a proliferation of the palmar aponeurosis. Every year, 100,000 to 150,000 people in Switzerland are diagnosed with Dupuytren's disease. 60 to 80 per cent of sufferers are men.
The connective tissue layer of the hand, known as the palmar aponeurosis, is a complex three-dimensional arrangement of longitudinal, transverse and deep fibres. The overlying skin is connected to it by another layer, which forms the superficial fascia under the skin with the hand. The palmar aponeurosis is an important stabilising factor in the act of grasping, as it enables close contact with the object being held without the skin shifting significantly. It also protects the underlying blood vessels, nerves and flexor tendons.
Gradual Dupuytren's disease
Dupuytren's disease generally develops slowly and usually over a period of years. Over time, the function and performance of the hand can be impaired to such an extent that even simple activities are only possible with difficulty. Surgery is then usually necessary. Initially, benign, soft, nodular changes form in the connective tissue of the palm. In the later stages of Dupuytren's disease, firmer cords appear along the finger tendons or extensive scarring. Gradually, the fingers become more immobile and full extension is no longer possible. Due to the curved fingers, it is no longer possible to lay the hand flat on the table in the advanced stage, as shown in Figure 1. This also leads to shrinkage of the joint capsule, especially in the metacarpophalangeal joints. The staging according to Tubiana(see table) provides information on the severity of the disease. Other diseases that are associated with Dupuytren's disease and can often occur at the same time are Ledderhose disease (same cord and lump formation on the sole of the foot) and induratio penis plastica (affection of the connective tissue on the penis).
Severity of Dupuytren's disease
Stage 0= no signs of disease
Stage N= lump formation
Stage 1= loss of extension between 0° and 45°
Stage 2 = extensor failure between 45° and 90°
Stage 3= extensor failure between 90° and 135°
Stage 4 = extensor failure > 135°
The degrees refer to a total loss of extension of all finger joints of a finger ray.
Conservative treatment methods
Conservative measures such as massages, ointments or gymnastics are generally unsuccessful. For some years now, it has been possible to treat individual strands with a drug that is injected into the strand. This is a collagenase Clostridium histolyticum. However, this procedure is reserved for completely circumscribed strands and leads to interruption of the strand. The nodules remain. In addition, the strands reappear more frequently and earlier.
Another therapeutic option is the needling procedure. This involves piercing individual strands with a needle under local anaesthetic until the strand breaks and the finger regains better extension. Treatment with X-rays is practically no longer used today, as the results are highly controversial.
Surgical treatment methods
Surgical treatment is still the most successful for the advanced, complicated forms with lump formation and severe finger curvature. The operation is performed under regional anaesthesia (anaesthesia of the arm) or general anaesthesia. In addition, a haemostasis is applied in order to be able to operate intraoperatively without blood and under optimal conditions. Magnifying glasses are always used. The incision is made in a zigzag pattern from the palm and, if necessary, up to the end joints. The skin is lifted away from the nodes and cords. The vessels and nerves must be carefully dissected out of the connective tissue growths. The cords and nodes are removed as completely as possible. The joint capsules of the metacarpophalangeal joints often also have to be detached.
In the case of very severe finger curvature, a skin defect may occur after full extension. In this case, flaps or skin grafts must be used to close the defect.
The procedure takes between one and two hours, depending on the severity and number of fingers affected.
Postoperative phase and long-term prognosis
A voluminous bandage is applied for a few days, partly as a compression bandage to prevent haematoma formation and partly as a "wicking effect" to absorb any small amounts of blood. Active and passive mobilisation is started very early on, with occupational therapy guidance if necessary. After two weeks, the stitches are removed and the hand can usually be used again without any major restrictions. The recurrence of connective tissue proliferation (so-called relapse) is possible and all the higher if one of the parents was already affected, if the disease occurs before the age of 40 and if the index finger and thumb are also affected. The risk is also higher in women than in men. Dupuytren's is nevertheless a benign disease and can usually be treated well by an experienced hand surgeon.
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PD Dr Andreas L. Oberholzer
FMH specialist in orthopaedics and trauma surgery. Areas of specialisation: Knee, hip and foot surgery.