Dupuytren's Disease

What Is It?
Dupuytren’s disease is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm). It often starts with firm lumps in the palm. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers (see Figure 1). Gradually, these cords may cause the fingers to bend into the palm (see Figure 2). Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

What Causes It?
The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.

What Are The Symptoms And Signs?
Symptoms of Dupuytren’s disease usually include a small lump or series of lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Gradually a cord may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop (see Figure 3). As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

Dupuytren’s Disease- Treatment Options
Treatment options for Dupuytren’s disease have changed significantly in the United States over the past few years. Currently there are four generally accepted treatment options for Dupuytren’s disease.

In cases of mild Dupuytren’s disease, which have been evaluated by a trained specialist, observation is certainly an appropriate treatment. In cases of mild Dupuytren’s disease, there is no need to restrict activities.
The standard treatment for advanced Dupuytren’s disease is open surgery, which involves removing all involved Dupuytren’s tissue to the affected digits/fingers. This is normally an outpatient surgical procedure performed with either a regional and/or general anesthetic. Postoperatively, the patient is placed in a splint followed by outpatient therapy.
A new injection therapy has been approved by the FDA. Specifically, a new collagenase drug which dissolves the involved Dupuytren’s cords (Xiaflex) has been developed. This medication is injected in the office followed by a manipulation in the office the following day. Patients interested in this treatment option need to be evaluated by a physician trained in the use of this product, where the pros and cons of this specific treatment modality can be discussed.
A procedure known, as a needle aponeurectomy (N.A.) has become popular in the United States. This procedure was developed initially in France and involves the releasing of Dupuytren’s cords with the aid of a small needle under a local anesthetic. This is a relatively simple office procedure. Not all patients are appropriate candidates for this procedure and once again each individual needs to be evaluated by a trained hand surgeon.

Regardless of what therapeutic options are decided upon, the most of people will require some type of therapy and/or splinting following their treatment. All procedures carry some risk of infection, nerve and/or vascular injury. In addition, as the underlying pathology and genetics are unchanged, all patients undergoing treatment are at risk for recurrence and/or extension of their Dupuytren’s disease.