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Dupuytren's contracture

Dupuytren's contracture is a fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended (straightened). It is named after the famous surgeon Baron Guillaume Dupuytren, who described an operation to correct the affliction. more...

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The ring finger and pinky finger are the fingers most commonly affected, but Dupuytren's contracture may affect any or all of the fingers. Dupuytren's contracture progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The palmar fascia becomes hyperplastic and undergoes contracture. As a result, the affected fingers start to bend more and more and cannot be straightened.

Incidence increases after the age of 40; at this age men are affected more often than women. After the age of 80 the distribution is about even.

Risk Factors

Regular operation of heavy machinery increases one's risk of developing Dupuytren's contracture; family history, diabetes, liver disease, alcoholism, epilepsy and pulmonary tuberculosis are also factors. Surgery of the hand may trigger growth of Dupuytren nodules and cords if an inclination existed before. Dupuytren's contracture may accompany fibrosing syndromes such as Peyronie's disease, Ledderhose's disease and Riedel's struma.

Treatment

  • Surgery (in cases of severe contracture)
  • Radiation therapy (specifically in early stages)
  • Needle aponevrotomy (removes the contracture)
  • Triamcinolone injections provide some relief

Surgical management consists of opening the skin over the affected cords of fibrous tissue, and dissecting the fascia away. The tendons can then be brought out to length. The procedure is not curative, and patients may need re-do surgery, however, the thickened fascia often invests the digital nerves and arteries, so there is significant risk of de-vascularization of the digit.

Treatment of Dupuytren's disease with low energy x-rays (radiotherapy) may cure Morbus Dupuytren on a long term, specifically if applied in early stages of the disease. Needle aponevrotomy is a minimal invasive technique where the cords are weakened through the insertion and manipulation of a small needle. Once weakened, the offending cords may be snapped by simply pulling the finger(s) straight. The nodules are not removed and might start growing again. Currently in phase III of FDA approval is another promising therapy, the injection of collagenase. This procedure is similar to needle aponevrotomy, however the chords are weakened through the injection of small amounts of an enzyme that dissolves them.

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Dupuytren's disease
From Journal of Bone and Joint Surgery, 9/1/01 by Burke, Frank

Dupuytren's disease. By Raoul Tubiana, Caroline Leclercq, Lawrence C. Hurst, Marie A. Badalamente and Evelyn J. Mackin. Pp 321. London: Martin Dunitz, 2000. ISBN: 1-85317-475-0. L65.00.

I enjoyed reviewing this book on Dupuytren's disease. The authorship is somewhat more extensive than is described on the fly leaf, with chapters added in an attempt to make the book more comprehensive and timely. This goal has been achieved.

The text was overseen by Lawrence Hurst, and the literary style is consistent and easy to read. The illustrations by Leon Dorn are superb and play an important part in clarifying the anatomy of the hand and the pathological processes associated with Dupuytren's disease. Some of the photographs failed to carry their intended message, and more extensive use of illustrations by Mr Dom for a second edition would seem appropriate.

I have very few criticisms. Professor Tubiana stresses the degree of contracture in relation to the timing of surgical intervention. I would have thought that some statement on the rate of progression should have been included, since it is the combination of these factors which triggers operative intervention. I tend to intervene early in a rapidly progressive contracture with a smaller extension deficit.

The rehabilitation section does not, to my mind, fully address the issue of the postoperative role of splintage or its duration. Many surgeons splint the fingers in maximal extension routinely for six months, but that protocol may represent unnecessary overtreatment. The role of postoperative splintage remains uncertain and needs clarification.

The senior author concludes the text with a succinct overview of the principles governing Dupuytren's disease which will be particularly useful for trainee surgeons wishing to gain an understanding of this confusing entity. I recommend this book to trainee surgeons in orthopaedics, particularly those with an interest in hand surgery. It will be a useful addition to any orthopaedic library.

Frank Burke.

Copyright British Editorial Society of Bone & Joint Surgery Sep 2001
Provided by ProQuest Information and Learning Company. All rights Reserved

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