eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Dupuytren Contracture: Treatment

Author: Steve Lee, MD, Physician in Plastic, Reconstructive, and Hand Surgery, The Samra Group
Coauthor(s): Michael Baytion, BS, Ohio State University College of Medicine; Mark F Hendrickson, MD, Chief, Section of Hand Surgery, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation; Derek L Reinke, MD, Consulting Staff, Cary Orthopedic and Sports Medicine Specialists; Yelena Bogdan, Stony Brook University Health Sciences Center School of Medicine (SUNY)
Contributor Information and Disclosures

Updated: Apr 6, 2007

Treatment

Medical Therapy

In the past, nonsurgical approaches to Dupuytren contractures such as splinting, irradiation, ultrasonography, dimethylsulfoxide, vitamin E therapy, and allopurinol treatment were shown to be ineffective. Steroids produced only temporary therapeutic effects, and their use has been debated in the literature. Future nonoperative therapies include the use of calcium channel blockers or gamma-interferon, skeletal traction, and percutaneous needle fasciotomy, with the last of these showing the most promise with minimal adverse effects.

Collagenase percutaneous needle fasciotomy is currently undergoing clinical trials. Preliminary results in a study by Badalamente and Hurst (1999) showed astonishing results of more than 90% correction of the MCP joint, 66% correction of the PIP joint, and minimal recurrence rates. Adverse effects included pain at the injection site, minimal swelling, and hematoma. Although collagenase also shows promise in clinical trials, surgical intervention for Dupuytren contractures is still considered the criterion standard.

Surgical Therapy

Although the option for surgery in Dupuytren disease is considered on a case-by-case basis, guidelines for the timing of surgery exist. In general, surgery should be performed on an affected MCP joint if the contracture is 30° or greater. Such contractures most likely cause some debilitation for the patient. Usually, a limited fasciectomy of the pretendinous cord is sufficient to establish normal function in the MCP joint.

McFarlane favors use of a regional fasciectomy of the pretendinous cord to prevent recurrence of Dupuytren contracture. For longitudinal incisions, Z-plasties or multiple Y-to-V advancements may adequately close the wound. A transverse incision may be necessary for more extensive disease; in such cases, a defect may require a full-thickness skin graft or necessitate the wound to heal secondarily.

The evaluation of a PIP joint in Dupuytren disease is different from that of an MCP joint, and the prognoses differ as well. In PIP joint contractures, one should clearly define the method to be used in surgery, as well as discuss with patients their expectations, occupation, and activities that may require use of their hands. Given the difficulty of correcting severe disease, fasciectomy is indicated for any amount of PIP joint contracture. Unfortunately, recurrence is common. The procedures of choice in the PIP joint are dermatofasciectomy or extensive fasciectomy.

Interestingly, Hueston (1984) discovered no recurrence with a full-thickness skin graft in dermatofasciectomy. Therefore, this technique is used for patients with an increased diathesis and an increased likelihood for recurrence. Extensive fasciectomy prevents recurrence because the entire diseased fascia is removed, along with the central, lateral, spiral, natatory, and retrovascular cords, as well as any normal fascia that may later be affected.

Preoperative Details

The surgeon and/or patient may choose either regional (local, median, or ulnar nerve block) or general anesthesia for the procedure. Regional anesthesia performed more proximally decreases tourniquet-related discomfort. Hurst uses Marcaine (bupivacaine HCl; Cook-Waite, Cambridge, Ontario, Canada) without epinephrine for its longer duration of nerve blockage. (Note: Regional anesthesia should not be used if the patient has any of the following conditions: coagulopathy, psychosis, peculiar and/or unstable personalities, or progressive neurologic disease.)

Intraoperative Details

Loupe magnification should be used for the procedure to aid visualization. The use of a tourniquet around the affected upper extremity also aids visualization of the lesion and control of blood loss. Depending on the location of the lesion, a transverse palmar incision may be used with a zigzag incision or a limited straight-line incision with Z-plasties over the affected digits.

The skin over the distal palm remains intact, with continued excision of the underlying fascia. For procedures in the PIP joint, excision of the palmar aponeurosis is most often performed, and the cords are removed. For dermatofasciectomy, a full-thickness skin graft is used to replace the diseased fascia and overlying skin. The surgeon must exercise care not to inadvertently excise the digital nerves. Before the wound is closed, the tourniquet is removed, and electrocautery is performed for hemostasis.

Postoperative Details

Proper postoperative care is essential for a successful surgical outcome. The protocol includes splinting in extension and an exercise regimen with a therapist for instituting range-of-motion exercises within the first week after surgery. Patients who undergo PIP joint surgery require 6 weeks of continual splinting, including splinting at night, for as long as 3 months to minimize secondary scar contractures.

Complications

Complications occur most often in patients who require extensive fasciectomy because of severe disease; McFarlane and McGrouther (1990) reported a complication rate as high as 17-19%. During surgery, complications may include severing of the digital nerves, most often the neurovascular bundle; the inadvertent creation of a buttonhole through the skin flaps during their separation between the skin and the fascia; and circulatory compromise secondary to trauma to the digital arteries.

Postoperative complications include loss of flexion, hematoma, skin sloughing, infection, edema, and reflex sympathetic dystrophy. The most common PIP joint postoperative complication is loss of flexion, which occurs in 6% of patients.

The triad of hematoma, infection, and skin loss occurs in 3% of patients. Hematomas most often form in the palm, and they may be prevented by meticulous hemostasis, by removing the tourniquet before the wound is closed, and by rapid evacuation of hematomas, which prevents necrosis of tissue and skin and decreases the risk of infection.

Elevation of the hand can prevent postoperative edema. Reflex sympathetic dystrophy more commonly occurs in patients with extensive fasciectomies and, thus, more aggressive disease. This idiopathic pain syndrome, which often occurs 3-4 weeks after the surgery, consists of pain, edema, stiffness, and vasomotor disturbances. Reflex sympathetic dystrophy occurs in 5% of patients, affecting 3% of men and 7% of women; treatment includes sympathetic blockade for symptomatic relief.

More on Dupuytren Contracture

Overview: Dupuytren Contracture
Workup: Dupuytren Contracture
Treatment: Dupuytren Contracture
Follow-up: Dupuytren Contracture
References
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References

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Further Reading

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Keywords

Dupuytren's disease, Dupuytren disease, fibromatosis, fibromatoses, Dupuytren's contractures, palmar contracture, palmar fascia

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Contributor Information and Disclosures

Author

Steve Lee, MD, Physician in Plastic, Reconstructive, and Hand Surgery, The Samra Group
Steve Lee, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Baytion, BS, Ohio State University College of Medicine
Disclosure: Nothing to disclose.

Mark F Hendrickson, MD, Chief, Section of Hand Surgery, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation
Disclosure: Nothing to disclose.

Derek L Reinke, MD, Consulting Staff, Cary Orthopedic and Sports Medicine Specialists
Disclosure: Nothing to disclose.

Yelena Bogdan, Stony Brook University Health Sciences Center School of Medicine (SUNY)
Yelena Bogdan is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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