Dupytren’s Contracture

Dupuytren’s contracture is a genetic disorder in which the fascia of the hand contracts so that the fingers no longer fully extend. What is fascia?  When you order a piece of meat, the tough gristle around the meat is fascia.  In the hand, the fascia is composed of tough linear structures that lie just below the skin, but above the tendons that move the fingers.

Dupuytren’s contracture most often occurs in people of Scandinavian (Viking) ancestry.  Now, the Vikings got around back when, so their genes often show up in people that don’t realize that they have some Viking ancestry in their family tree.

Dupuytren’s contracture often starts as a nodule in the hand.  This nodule may be tender.  Over time, the nodule grows and becomes a rope-like ‘cord’ that progressively pulls the digit closed.  The rate of progression is genetically determined, but it can be accelerated by trauma.  It’s not affected by work.  There’s really nothing that can be done to slow down its progression; stretching is not effective.  A tender nodule can be injected with steroid to decrease tenderness.

The Dupuytren’s cord should not be surgically removed until there is a contracture / loss of ability to extend the finger.  This is because prematurely removing immature disease can speed up the disease’s progression.  The best time to have it excised is when the metacarpophalangal (MP) joint – the big knuckle where the finger attaches to the hand – loses 30 degrees of extension, or the proximal phalangeal (PIP) joint – the middle knuckle of the finger – becomes noticeably involved.

As with many conditions, it’s a lot easier to treat Dupuytren’s Contracture early rather than late.  Treatment options include Xiaflex, an enzyme that can dissolve part of the cord, Needle Fasciotomy, where the cord is cut with a needle in the office, or surgery.  Both Xiaflex and Needle Fasciotomy are used primarily for MP joint contractures and do less well with a higher complication rate, when used to treat PIP joint contractures.  Both Xiaflex and Needle Fasciotomy have much higher recurrence rates than surgery.  Both work about the same. In fact, a recent research paper compared Xiaflex to Needle Fasciotomy and showed no difference in outcomes between them.1

Xiaflex is expensive ($3,000-4,000), but insurance companies may pay for some of this.  Needle Fasciotomy uses just a needle, which is cheap. Needle Fasciotomy can be performed in the office during a single visit.  Xiaflex injections are also performed in the office, but need to be set up in advance.  The enzyme is injected in the clinic, and then the cord is ruptured the next day in clinic, so back-to-back clinic visits are involved.

Needle Fasciotomy improves contractures approximately 70%, with 30% remaining.  It works better for the MP joint (80% gain in extension), compared to the PIP joint (54% gain in extension).  At 2.5 years, the recurrence rate is 65%: 54-60% of PIP joint contractures recurred, while only 14% of MP joint contractures recurring.  42% underwent another procedure to treat their recurrent Dupuytren’s Contracture.  At 5 years the reported recurrence rate is as high as 85%.  The risk of nerve or artery injury is roughly 5%.  66 tendon lacerations were reported in a single physician survey.  Therefore, Needle Fasciotomy is used best to temporize the situation.

The Fascia of the Palm

In Dupytren’s contracture the palmar fascia becomes diseased.