DUPUYTREN'S

By Ray Foster


This is one of a number of Medical Checkpoints giving information about common conditions and what you can do about it. Your opinion and reaction to these Medical Checkpoints would be valued and appreciated. Medical Checkpoints are published periodically by NEWSTART Healthcare and are provided as a free service.

 

DEFINITION

from Campbell's Operative Orthopaedics, 8th edition, edited by A. H. Crenshaw, page 3427 (Dupuytren's Contracture):

 

Dupuytren's contracture is caused by a proliferative fibroplasia of the subcutaneous palmar tissue, occurring in the form of nodules and cords and resulting in secondary flexion contractures of the finger joints. Other secondary changes include thinning of the overlying subcutaneous fat, adhesion of the skin to the lesion, and later pitting or dimpling of the skin.

 

What is going on:

A cord or tissue is first felt in the palm of the hand with extension of the fingers. Later this cord becomes thicker and tighter until there is a contracture of the finger so that with the wrist straight, the finger cannot be straightened out at the same time. This is caused by the protective tissue deep to the skin of the palm of the hand becoming abnormally thickened, cord-like, and then tightening down. This restricts the movement of the finger, usually the ring finger first, but any finger may be involved. There is no pain involved. The problem is the lack of range of movement of the fingers and the deformity that it causes. In the fifth to seventh decades of life Dupuytren's contracture is 10 times more frequent in men than women. Scandinavian and Celtic origin individuals experience Dupuytren's contracture more often than Blacks or Orientals. The contracture is more frequent and severe in persons with epilepsy (42%) and alcoholism. The contractures are bilateral 45% of the time, but rarely symmetrical. The cause of Dupuytren's is unknown. There is evidence that heredity is a factor. About 5% of patients experience a similar thickening of the fascia of the feet, known as Ledderhose' disease. "Knuckle pads" (thickening of the skin over the knuckles) are seen on the finger joints of some patients.

 

What to do:

1. What to do depends entirely on how much of a problem the contracture is. While there is no study showing that it helps, it would seem reasonable to rub in some vitamin E into the contracture in the early stages. While this may not stay the very slow but relentless progression, - it will do no harm and will tend to make the skin softer because vitamin E is sold in capsules as an oil. Prick the capsule with a pin and express a bit of the oil and rub into the area. The pin can be put back into the hole until used again. The rationale why this may help is not only the oily properties making the skin softer, but vitamin E tends decrease the activity of "free radicals" which may contribute to the development of the contracture. The action of vitamin E is described in Harrison's Textbook:

The vitamin probably acts as an antioxidant rather than as a specific cofactor. In so acting it presumably inhibits oxidation of essential cellular constituents and prevents the formation of toxic oxidation products. Other antioxidants such as selenium, sulfur-containing amino acids, and the ubiquinone group can reverse the symptoms of vitamin E deficiency in animals.

 

2. Surgery: The decision concerning surgery is basically the only other question regarding Dupuytren's contractures. To the question: "Should I have surgery?" The answer is on the basis: "How much trouble does the contracture cause me?" Dupuytren's contracture is not like cancer, i.e. "you do not need to get it before it gets you". You know what you have. That is all you are going to have for a long time (years, most likely, but certainly months before there is much change). If at this point you cannot live with it, then you should have surgery. Surgery is the only rational "cure" for Dupuytrens. It must be understood that the surgical "cure" does not change the chemistry or biology that is making the contracture. Because we do not know what that chemistry or biology is, we cannot reverse that or cure in the real sense. But surgery does get rid of the contracture for a very long time. If it took 40 or 50 years to develop, even if it took half that time to come back again, that is long enough to be free of the contracture for most people.

 

3. Having made the decision for surgery, what are the surgical options? Basically there are two options:

a) simply dividing the bands of Dupuytren's contracture tissue and

b) removing the bands more or less completely.

The operation of choice is to remove the bands as completely as possible. This gives the best chance for the longest relief before the tissue grows back again.

 

 

 

4. What is the post operative program? This is something that should be discussed with your surgeon. What the surgeon will plan for you is directly related to how much Dupuytren's tissue needs to be removed and what secondary joint contractures you have as a result of the Dupuytren's. The principles are that most likely a splint will need to be worn for some weeks or months to prevent the contracture re-forming while the surgery heals. In general it is better not to delay surgery until fingers and joints are so stiff that it makes their recovery difficult.

 

5. What are the Risks of Surgery? Risks are associated with the anaesthetic and with the surgical procedure. An anaesthetic of choice is a nerve block (axillary block). Assuming that there is no sensitivity to the local anaesthetic, there is about the same anaesthetic risk as for having a tooth pulled in most cases. The surgical risk itself is related to how extensive the surgery is. If a large amount of Dupuytren's tissue must be removed, there is risk of skin healing and the possible need for skin grafting. In most cases skin closure is possible with a technique called "Z-plasties" where the skin is closed primarily. As for any operation there is always a slight risk of infection. Every precaution is taken to minimize this risk. This is one reason why surgery center or hospital surgery is preferred.

 

6. Prognosis: How soon will the Dupuytren's contracture grow back again? The best guide to that is how fast it grew in the first place. Other factors include a family history, sex (males have more trouble with re-growth than females), alcoholism, and epilepsy are unfavorable factors.

 

7. Prevention: There is no generally agreed methods of preventing Dupuytren's contracture. We at present know of no way to control the factors that are associated with the tendency for the contracture to recur after surgical removal. Using vitamin E to rub in locally may help.

Feedback:

Caller 7-29-03 from Canada told us that he had treated his pain from Dupuytren's contracture in his hand with drinking Noni juice daily for several months. He stated also that the Dupuytren's contracture cords in his hands got softer.

It has been the experience of some that vitamin E oil rubbed into the early Dupuytren's contracture cords in the hands get softer and tend to fade away.

What has been your experience? Call us and let us know (605) 255-4101 or email us at rlf@mt-rushmore.net