• Definition: Benign connective tissue transformation and tumour of the palmar and digital (finger) fascia that tends to be phase-like and most frequently affects men over 50. It is not a disease of the flexor tendons. At an early stage it is not possible to say with certainty which patients will develop contracture with extension deficit of the finger joints or in which patients Dupuytren’s disease will become Dupuytren’s contracture. The biological severity index estimates this risk. Although this indeed is tissue proliferation, it is not cancer, does not grow invasively into other tissues, and does not form metastases.
• Overview: The palmar fascia is a coarse connective tissue coating situated deep inside the palm under the subcutaneous fatty tissue and protects the underlying pressure-sensitive structures such as blood vessels and nerves. It consists of connective tissue cells. In Dupuytren’s contracture, these connective tissue cells change (metaplasia) and can shrink or contract, forming newly altered connective tissue fibres. This causes otherwise harmoniously structured connective tissue fibres of the palmar fascia to become shortened strands and nodules.
• Symptoms: The disease is usually painless and characterised by the formation of nodules and strands in the palmar fascia, which, if they shorten, can lead to extension deficit of the finger joints. If this condition is not treated promptly, the capsules of the finger joints may also contract and affect the extensor apparatus of the fingers. The ring finger and little finger are most commonly affected.
• Diagnosis: The medical history and clinical examination are characteristic (pathognomic). Further examinations are indicated only in very unusual cases.
• Differential diagnoses: Other rare tissue generation diseases.
• Therapy: As with diabetes, although the disease can be treated it is not curable. It is not the disease itself that requires treatment, but rather the associated extension deficit of the finger joints. If you can no longer lay your hand flat on a tabletop (tabletop test) or put our hand into your pocket (pocket test), you should seek medical advice. With this disease, the timing of therapy is important. To avoid unnecessary therapeutic intervention, it should not be started too early. It is, however, not advisable to wait too long either, as treating a pronounced stretching deficit has worse results. The goal is to find the golden mean between the two extremes in order to restore finger extension with as limited a number of interventions as possible in the course of a patient’s life. Depending on the severity, progression and risk of an aggressive development (biological severity index), the condition can require either no therapy (nodular & strand formation without extension deficit), minimally invasive therapy, or open surgery. There are two therapeutic approaches: the shortened section of the palmar fascia is either severed (-tomy) or removed (-ectomy). Severing has a lower risk of complications but a slightly higher risk of recurrence; it is minimally invasive, making it suitable for patients with a slowly progressing disease, a few affected fingers only, and thin strands. Surgical removal of the diseased strands and nodules has a lower risk of recurrence and a slightly higher risk of complications. In certain cases, the procedure can be combined with a skin graft to further reduce the risk of relapse. The minimally invasive severing of the shortened strands is performed by needle perforation (percutaneous needle fasciotomy) under very superficial local anaesthesia or by a short skin incision. Another option is to inject an enzyme (Xiapex) that partially dissolves the diseased connective tissue of the shortened strands. The contrasting option is open surgery. The skin above the nodules and strands is opened in a zigzag pattern and the nerves and vessels are carefully laid free. The altered connective tissue is then surgically removed. Depending on stage and progression, the procedure can be supplemented by local advanced flap (plastic) surgery or a skin graft taken from the ball of the little finger, the forearm or the elbow. If the skin on the palm is not sutured, the defect closes spontaneously within a few days, yielding an aesthetically and functionally good result.
• Post-operative care: Open surgery is often performed as part of an in-patient hospital stay, while minimally invasive techniques are performed on an outpatient basis. Patients must ensure their operated hand is kept elevated, as the risk of postoperative bleeding is somewhat higher with this procedure. Application of a night stretching splint for the finger joints and a special splint treatment during the day depends on the extent of the stretching deficit and the flexion contracture of the finger joints. The hand is either immobilised (approx. 14 days) until the skin transplant has healed or otherwise (no transplant) remobilised relatively soon. Ergotherapeutic post-operative care with scar massages, compression gloves and splints is often indicated.
• Prognosis: As the disease cannot be cured, the same area may be treated several times during the patient’s lifetime, or a newly affected finger ray may require a two-stage operation. Prophylactic therapy (irradiation) is recommended only in case of very aggressive disease progression. Complete recovery of finger extension depends on the extent of the stretching deficit, flexion contracture of the finger joints, and possible weakening of the extensor tendon. The risk of nerve or vascular lesion increases with each new intervention in the already treated area. The skin often takes a little longer to heal after surgical procedures than with other palmar procedures.