Dupuytren’s disease is a benign but progressive condition affecting the palmar fascia — the layer of fibrous tissue that lies beneath the skin of the palm and fingers. It is inherited and it is more commonly seen in men with 5 males for every female affected.

The palmar fascia layer starts to thicken in places forming firm nodules or sometimes little crevices. Often it will progress to form cords that tether the skin and pull finger joints into a bent position.

It can be sore when it first starts to develop but most cases do not experience pain.

The little or ring fingers are most commonly affected but other fingers or thumb can also be involved. A few patients are unfortunate enough to have all of their fingers and thumbs involved but it is much more usual to find one or two fingers with dupuytren’s disease

The speed and extent of progression is variable – some cases may never develop more than a nodule in the palm or the finger, some will develop contracture over many years and others may progress to finger contractures within a few months.

Each finger has 3 joints, here again there is variability with the number of joints affected and the extent to which each joint becomes involved.

With increasing contracture angles patients will start to find that manual tasks and activities become awkward. Putting on gloves, shaking hands, washing face, reaching into a drawer or pocket are all common activities which can be affected.

• A firm lump or cord in the palm, just under the surface of the skin.
• Puckering, pitting or dimpling of the skin in the palm
• The cord or lump appears to prevent full straightening of adjacent finger(s) – this cannot be overcome with stretching or exercising
• Dupuytren’s disease is not usually painful; if you have pain or tingling it could be that you have another common hand condition (carpal tunnel, arthritis or trigger finger for example)

Also known as percutaneous needle aponeurotomy
Needle fasciotomy is the least invasive treatment for Dupuytren’s contracture. Using a hypodermic needle inserted through the skin at multiple points, the Dupuytren’s cord is weakened and disrupted. There is no surgical incision, simply a line of small skin punctures and sometimes a small hole. No stitches are required.

The procedure typically takes 20 minutes and it is awake surgery using local anaesthetic injections at the start.

The small skin puncture sites heal quickly, there is a sticking plaster and patients can commence gentle activities straight away.

Needle fasciotomy is mainly effective in treating contractures which arise from cords in the palm and which bend the metacarpophalangeal (MCP) joint (this is the joint which connects the finger to the palm). If there are significant contractures at the mid-joint of the finger (PIP Joint) these do not typically respond to needle fasciotomy.

Because it does not remove any tissue it has a recurrence rate of 50% at 2 years but its convenience often makes it an advantageous choice and fingers on both sides can be treated simultaneously if necessary. It can be repeated in the future or other treatments can be used subsequently.

Fasciectomy is the most commonly performed surgical treatment for Dupuytren’s disease and is considered to be the standard for most patients with established Dupuytren’s contracture. Curved or zig-zag incisions are made in the palm and finger. This exposes the Dupuytren’s tissue and allows it to be carefully dissected and removed. There are important nerves and vessels immediately adjacent and in some cases the Dupuytren’s tissue wraps around or adheres to these making dissection complex.

It can be done with awake or asleep surgery. Dressings and bandaging are used and sometimes a splint as well. The surgery itself causes tissue disturbance and scar formation. The strength and duration of this response is very variable from one patient to another. You will need hand therapy as part of your treatment and this is usually commenced within a fortnight of operation. Early movement and activities are encouraged but it will take 6-12 months for all the swelling to settle and for the final outcome to be realised.

The MCP joint will usually correct well but the PIP joint is much less predictable and typically some contracture will persist. A small proportion of patients will have a difficult recovery and may end up with minimal benefit.

Where there is complex or recurrent disease, Dermofasciectomy may be recommended. This means that a section of skin is removed and a skin graft is used to make up for the gap that results.

The rationale is that skin from outside the palm does not carry Dupuytren’s-affected cells, so grafted skin is significantly less likely to develop new disease.

These cases are typically more complex for surgical dissection and there is additional complexity to harvest (usually taken from the arm) and place the skin graft.

The healing process is more complex and it relies upon the graft ‘taking’.
Recovery is longer and the outcome is more variable than for standard fasciectomy especially if the graft doesn’t take. It will take approximately 1 year for tissues to fully settle and for the graft to mature.