Dupuytren`s Contracture

Dr. Alon Covo

Dupuytren`s Contracture is a disease of the connective tissue causing damage to the proteins composing this tissue – collagen and elastin.

Scarring lumps appear on the connective tissue beginning at the wrist, causing it to thicken and contract/shorten.

The ring finger and little finger are typically the first to suffer from this.

Initially we would feel these lumps at the base are of the ring and little fingers which may be sensitive to touch, we will see pores in the palm skin, the skin will look wrinkled and will harden. Eventually we will see and feel a sub-dermal strand from the palm to the fingers and will feel limitation to the fingers' mobility. With time, the strand contracts and draws the fingers to permanent bending towards the palm. At the end of this scarring process the finger remains contracted and is incapable of straightening.

Causes for Dupuytren`s Contracture

The cause of this disease is unknown but studies point at a possible auto-immune reaction in which the body's immune system fails and forms antibodies destroying tissues and cells in the body.

There are researchers who believe that this disease is hereditary.

It was found that alcohol consumption and smoking increase the risk for the formation of Dupuytren`s Contracture. People with Diabetes Mellitus or Epilepsy who take balancing medications are more vulnerable for the contracture's formation.

Frequency of Dupuytren`s Contracture

Dupuytren`s Contracture is more common in the palm, but occasionally appears in the foot (Ledderhose Disease) or in the male genital (Peyronier`s Disease). Dupuytren`s Contracture typically appears in men of north-European descent above the age of 50.

Diagnosing Dupuytren`s Contracture

It is highly important to be examined by an orthopedist / hand surgeon in order to assess the disease's severity.

The 'Table Test' - this test is simple and involves placing the hand on a table, with the palm turned towards the table. If there is no gap between the palm and the table, from the wrist to the fingers, there is no contracting of the fingers, and thus no Dupuytren`s Contracture.

A hand surgeon will also check the holding capability and movement range of the fingers.

Treating Dupuytren`s Contracture

The treatment procedure will be decided upon based on the disease's severity.

 

Using a splint - in mild cases, it is possible to use a splint which sets the fingers during the night - a short-term solution.

 

Injecting the enzyme Collagenase - injecting an enzyme causing the destruction of collagen composing the connective tissue. Recently the enzyme Collagenase is also injected into the ligament area. The enzyme contains proteins causing the breaking and weakening of bonds inside the ligament tissue. 24 hours after the injection, under local anesthesia, the physician performs a stretching of the fingers and tearing of the treated ligaments until the fingers are straightened. In some cases there is need to use a splint to hold the finger in its straight position until full recovery is achieved.

 

It is strictly forbidden to perform the action of straightening the finger, pulling or pressing it independently by the patient. Keeping the finger's bent position helps the active ingredient which was injected into it to do its job.

 

In case the initial injection was not effective it is possible to repeat it one month after the initial injection and up to three injections in total.

 

The injected enzyme is certified for use in Europe and the United States but is not certified by the Israeli Ministry of Health. It is possible to import it by Form 29ג of the Ministry of Health, signed by the physician or pharmacy.

 

Advantages - alternative treatment to surgery with all its implications, such as: complications and long-term recovery.

 

Disadvantages - this process does not suit every person. There are risk factors such as: anaphylactic shock, blood coagulation problems, pregnancy, age.

 

Side Effects - swelling, bleeding and internal bleeding, pain, inflammation – these side effects typically disappear within a few days.

At this stage, it is only possible to treat one finger with a waiting time of one month between treatments.

 

Cutting the ligaments - under local anesthesia, the ligaments are cut by a needle inserted under the skin.

Advantages - there are no cuts to the skin and in most cases there is almost no need for physical therapy following the operation, the procedure is quick and allows a return to activity within a few days.

Disadvantages - a risk of injuring sense nerves of the fingers of tendons, straightening the finger is not perfect and there is a higher frequency of a return of Dupuytren`s Contracture.

 

Surgery - removal of the diseased tissue from the palm by exposing and amputating the ligament causing the contracture. The operation is carried out under general anesthesia.

Advantages - a great improvement of the finger's movement range up to complete straightening.

Disadvantages - surgical intervention may be complicated due to multiple attachments to the surrounding tissues as well as the change to the hand's regular anatomy, increasing the risk for damage to nerves and blood vessels, infection, long post-operation recovery time – treating the wound caused by the surgical operation and a need for a prolonged physical therapy.

Recommendations after surgery of Dupuytren`s Contracture - lifting the hand for several days in order to prevent swelling, removal of sutures after 10 days, replacement of the cast with a splint, and physical therapy.