Have you developed lumps and bands in your palm(s) or fingers which are starting to prevent you from fully extending your fingers? This is probably Dupuytren’s Contracture. It’s a common condition which runs in families. Treatment of the lumps before contracture has occurred is unnecessary but intervention should happen before contracture has progressed too far. Treatment options are collagenase injection; needle fasciotomy; formal surgery.
Dupuytrens contracture appears as lumps and bands of scar tissue beneath the skin of the palm and fingers. The tendons, nerves, and blood vessels are not directly involved.
The lumps in the palm are often tender at the beginning (and for months after) but this gradually settles. If they are not too painful and not causing finger contracture they can be ignored. If tenderness is a problem then a cortisone injection into them will often relieve the tenderness.
An established band in the palm can be released by needle fasciotomy, particularly if it is stopping only the metacarpophalangeal joint (closest to the palm) from straightening. After injection of local anaesthetic, the band is cut through using the bevel of a hypodermic needle via just pinpricks in the skin. This is a clinic procedure and can often be done at the time of the initial consultation. It may defer the need for more formal surgery for a variable length of time and possibly indefinitely.
Another option more recently available is to inject collagenase, an enzyme which softens the Dupuytrens tissue. Two days later the bands can be broken by forcibly extending the fingers.
When the finger contractures involve more joints and the scar tissue is not presenting as simple bands, formal surgery is necessary. This is a hospital operation requiring an anaesthetist. It may be done under general anaesthetic but often is done with an arm block. The anaesthetist injects local anaesthetic into the armpit which makes your whole arm go numb. The operation can then proceed with you awake. The decision, general anaesthetic or armblock, is yours in discussion with the anaesthetist.
I normally access the abnormal tissue with zigzag incisions in the palm and affected fingers. After removal of the scar tissue you have lots of small stitches in the skin. I leave the bandage on only 3 to 5 days. After that you can usually have your hand free and get it moving. Bear in mind that the treatment does not fix the genetic tendency to develop this problem. It removes only what is there at the time. Recurrence at the same site and new areas of contracture are likely but the appearance of these and the rate of development is entirely unpredictable. You may have more within a year – it may never trouble you again.
Dupuytren’s contracture doesn’t usually occur in those under 50. The earlier Dupuytren’s contracture appears the more aggressive it is likely to be. When it appears in the thirties (rarely) it is common for a person to require several operations over the decades that follow. In severe cases, and particularly in recurrent cases, overlying areas of skin may become sufficiently involved that some skin must be removed as well, necessitating a skin graft.
Post operative care
It is not a particularly painful operation. People often say, particularly after an arm block where the hand stays numb for 12 hours or so, that they have experienced no pain at all.
You need to have your hand elevated in a sling with your hand at shoulder level for 24 hours.
With Dupuytrens contracture, it’s important not to postpone surgery too for long! The interphalangeal joints (those within the fingers) are particularly vulnerable to become secondarily stiff if prevented from straightening for too long – especially if they are contracted more than 45 degrees. In this situation, surgical removal of the Dupuytrens scar tissue may not achieve full straightening.
Rarely this surgery can leave a finger that cannot be fully flexed. A post-operative infection could cause this. Post-operative immobilisation can also be the culprit. This is avoided by early removal of bandages and mobilisation as described above.
Nerve injury: the scar tissue lies close to and often around the (digital) nerves which give your fingertips sensation. There will normally be patches of numb skin the palm where the skin has been lifted for access but injury to the digital nerves is extremely rare in “virgin” cases. For re-operation where there has been recurrence, the digital nerves are more at risk as they may be “clasped” by scar tissue but nerve injury can still nearly always be avoided. In these recurrent cases, the greater degree to which the nerves must be “handled” means that they may stop functioning temporarily.
out of town?
Ideally a consultation should be face to face but is certainly possible to arrange a telephone consultation. If you can email the photos first so much the better. If it is clear what procedure is required then the in-person consultation can be the day before or the morning of the surgery.