Dupuytren's Contracture: The Bent Finger
Dupuytren Disease is a disorder that results in a slowly progressive thickening and shortening of the tissue on the palm side of the fingers and hand. It eventually leads to finger contractures - decreased motion - and these can be debilitating. In 1614, Plater first described the condition in a mason with flexion of his fourth and fifth fingers. Guillaume Dupuytren (1777-1835) was Napoleon's surgeon. In 1831 at the Hotel-Dieu Hospital in Paris, he devised an effective surgical approach to treatment through palmar fasciotomy and then lectured on a condition causing bent fingers, which since has borne his name.
Some have thought The Papal Benediction sign, with a bent ring and small fingers may have started with a pope with the condition.
Dupuytren contracture is most commonly seen in people of Northern European descent and affects 4-6% of caucasions worldwide. Many individuals have bilateral disease (45%). The ring finger is most commonly involved, followed by the fifth digit and then the long finger. The index finger and the thumb are typically spared. Males are 3 times as likely to develop the disease and are more likely to have a higher disease severity. It generally affects individuals older than 50 years of age. Dupuytren Disease is uncommon (< 1%) among Indians, Native Americans, and patients of Hispanic descent.
Dupuytren disease is a genetic condition with variable penetrance. Other risk factors include alcoholism, diabetes mellitus, manual labor with vibration exposure, prior hand trauma, smokers, hyperlipidemia, Peyronie disease, and complex regional pain syndrome (CPRS). Interestingly, rheumatoid arthritis seems to protect against the development of Dupuytren disease.
It typically presents with a palmar nodule and cord adherent to the skin. This often causes a flexion contracture of varying degree. Generally, the contracture will progress over time and the finger(s) will not be able to straighten at all. This reduced range of motion will be a challenge for patients. Fortunately, this condition is not painful.
Treatment includes observation until a contracture progresses to a point where intervention is necessary. This would include the first knuckles having a contracture of 30° or greater, the second knuckle having a contracture of 5° or more or if the contracture causes an interference with activities of daily living. All treatments are invasive and Dupuytren's Disease does have a rate of recurrence, with any of these treatments.
Percutaneous needle fasciotomy involves cutting the cord using a needle through the skin under local anesthesia.
Collagenase Clostridium histolyticum (Xiaflex) percutaneous needle fasciotomy was approved by the FDA in February 2010.
This involves an injection of an enzyme into the cord. The enzyme degrades the tissue and the cord breaks yielding a straight finger. This procedure is also done under local anesthesia and it requires a visit to your hand surgeon the following day. This is really a new and exciting technique. It is non-surgical and does not require therapy. For more information on this exciting technique, click here.
Surgery is the final option. This involves a trip to the operating room. There are a number of surgical options involving varying degrees of invasiveness however which surgery that is chosen is best left up to your hand surgeon. It usually involves removing the entire cord. There is a recovery afterward.
Proper postoperative care is essential for a successful surgical outcome. The protocol includes splinting in extension and an exercise regimen with a certified hand therapist for instituting range-of-motion exercises within the first week after surgery. Rehabilitation following surgery is a gradual process of increasing activity and decreased splinting to achieve increased range of motion. Return to normal activity is expected in 2-3 months.
If you suffer from Dupuytren's Disease, consult your physician or hand surgeon for advice and options.