PALMAR CONTRACTURE DUPUYTREN’S DISEASE
What is it?
Dupuytren’s disease is an abnormal thickening of the palmar fibromatosis, also known as palmar aponeurosis, situated just beneath the skin of the palm, above the palmar tendons and nervous-vascular elements. The palmar aponeurosis is a spatial “scaffolding” of the hand.
What causes it?
Dupuytren’s disease is a congenital disease, which has probably originated from Scandinavia. It is handed down from generation to generation as an autosomal dominant trait with an incomplete penetrance of of a gene.
What are the symptoms and signs?
Symptoms of the Dupuytren’s disease usually include changes in the appearance of the skin and deterioration of hand functioning through gradual fraction contracture of fingers.
The disease manifests itself in thickened areas beneath the skin, which initially look like individual nodules. Changes in the form of nodules are usually located in the palm. As the disease develops, the nodules get thicker and absorb the skin above them. Gradually a cord may develop resulting in shrinking of the skin, which in turn causes bending / closing of a finger / fingers.
The thickened areas may also appear on the palmar side of fingers, soles of the feet (plantar fibromatosis) and even on the penis. In such cases we deal with the Peyroni disease.
The disease process may apply to a few fingers which causes a considerable loss of hand functions. In some advanced phases of the disease, using one’s hand becomes impossible due to closure of a few fingers. Although the diseases process is often wrongly associated with affecting the tendons of the bending fingers, the disease does not apply directly to them. In the course of the disease it usually develops without pain. In some cases the overgrown palmar tendon, which results in the patient’s disturbance of feeling in these fingers,
Examination and diagnosis of the disease
Diagnosing of the disease is based on an interview concerning development of the disease, location of the first thickenings and of dynamics of their growth, as well as progress of worsening functions of the hand. The disease is not typically painful though in certain cases it may be accompanied by finger dysaesthesia due to compression of the palmar digital nerve by an overgrown palmar aponeurosis. Examination of the hand allows to assess the number of fingers involved in the disease process, the degree of impairment of their functions (assessment of finger extension), the condition of the skin involved in the disease process.
Treatment
Thickening / overgrowth of palmar aponeurosis not causing limitation of finger extension does not mean that treatment is required.
Development of a significant impairment of finger extension means that treatment is required.
The treatment may be non-operational, (e.g. applying injections dissolving the overgrown palmar aponeurosis – the technique not allowed to be applied in Poland; hypodermatomy of the palmar aponeurosis with a needle) or operational – surgical aponeurectomy. The operation requires extensive experience from a surgeon and special training in the field of microsurgery, because during the surgery it is necessary to dissect the nerves, arteries and palmar veins absorbed by the disease process. Very often, it is also necessary to release the immobilized finger joints, which due to long immobilization, underwent stiffening. Typically, the wound is sutured by making complicated dermoplasty. Sometimes it is necessary to use skin grafts. In certain cases the wound is left non-sutured. A surgeon may decide to use wires to support the extension of a finger following the aponeurectomy and release of the finger from palmar contracture. Wires are applied for a short time. It is also possible to apply advanced devices helping to maintain the extension of fingers, but they are not often applied due to the cost of their use.
Patients should also be informed that a long-lasting stiffening of a finger in a contracted position may result in shrinkage of arteries, veins and palmar nerve/nerves, and achievement of its/their full extension may prove to be impossible. It may happen that in very advanced cases a patient may lose his/her finger due to its ischemia.
Follow up
After an operation, a dressing is applied to the hand. A plaster cast can also be applied in order to help fingers maintain the required extension. Starting from the first day after the operation, a patient should exercise bending and, particularly, straightening his/her fingers. The dressing / cast should be changed every day, unless a dermal graft was applied. Then. the surgeon decides when the dressing / cast is to be changed.
In order to reduce painful suffering connected with the operation, it is enough to apply the “usual” painkilling drugs and have one’s arm in a sling. The hand should not be strained with workloads for about one month. A surgeon may also recommend physiotherapy in a specialist rehabilitation centre.
Sutures can be removed two weeks after the operation at the earliest, though the last sutures are often removed later.
A patient must remember that only the part of the palmar aponeurosis which was pathologically overgrown is removed during an operation. The disease can sometimes recur in the place where it was cut out or develop in another part of the hand. It is connected with the congenital nature of the disease.