dupuytren Contracture
Dupuytren contracture, also known as palmar fibromastosis, is a genetic condition seen most commonly in individuals of northern European descent. The condition can result in abnormal growth of tissues in the palm of your hand, either in the form of “nodules” in the palm or “cords” in line with the fingers. Over time, these tissues can contract and result in the finger curling down into the palm.
The cords and nodules are not usually painful, by if they progress and grow, they can result in an inability to fully open the hand. This can cause problems with wearing gloves, placing hands into pockets, and other normal activities.
For mild cases, watchful waiting is usually advised. As contractures develop and affect function of the hand, other interventions can be considered. This typically involves 1) collagenase injection (Xiaflex), 2) needle aponeurotomy or 3) surgical excision.
Xiaflex
Xiaflex is a FDA improved medication that is injected into the cord, and has been shown to be effective at dissolving and breaking the cord. The medication is a collagenase, meaning it is an enzyme that dissolves collagen, the abnormal tissue present in the cord. Xiaflex treatment involves two steps.
Step 1 - Xiaflex injection:
In the office setting, local anesthesia (e.g. lidocaine) is injected into the skin to numb the finger
Next, the Xiaflex medication is injected at multiple sites throughout the cord. There are several potential side effects of the medication, including pain, swelling, bruising, and itching
After the injection, the patient is instructed to gently stretch the finger over the following days, and oftentimes the cord with be disrupted with an audible snapping sound
Step 2 – Manipulation (straightening) of the finger:
Within 7 days of the injection, the patient returns to the office for a manipulation if the finger is not yet acceptably straight
Local anesthesia (e.g. lidocaine) is again injected to numb the finger
The finger is straightened by the physician, resulting is disrupting of the cord
Sometimes during the manipulation, the skin on the palm of the hand may tear. This is typically treated with daily bandage changes as new skin fills in the defect
The patient is sent to a hand therapist in the office, who makes them a custom splint to hold the finger extended. This is worn when sleeping for 3 months to decrease the chance of recurrence
Xiaflex clinical trial results (Hurst et al. New England Journal of Medicine, 2009)
Metacarpal-phalangeal (MP) joint contractures (129 patients):
77% of patient within 5° of straight
Average improvement in range of motion of 41°
Proximal interphalangeal (PIP) joint contractures (67 patients):
40% of patients within 5° of straight
Average improvement in range of motion of 28°
More information on outcome data is available on the manufacturer’s website
Needle Aponeurotomy
Needle aponeurotomy is more popular in European countries, and involves placing a small needle through the skin under local anesthesia. The tip of the needle is used as a “knife” to divide the Dupuytren cord.
Surgical Treatment
While surgical excision of the diseased tissue is more invasive than the other two options, it has the benefit or removing all of the diseased tissue, rather than simply dividing or snapping the cord. This may result in a lower recurrence rate.
All treatment options have unique benefits, and oftentimes the specific location and extent of involvement makes one preferable to the other. The ideal treatment is best chosen after a thorough discussion with your physician. After all treatment options, hand therapy may be needed to optimize motion of the fingers. Oftentimes, wearing a splint at night for the first 3 months after treatment is done to hold the finger straight and decrease the chance of recurrence.
For more information about Dupuytren contracture, read the blog article written by Dr. Schreiber.
Dr. Schreiber is a board certified orthopedic surgeon specializing in hand, wrist, and elbow conditions. Dr. Schreiber practices at the Raleigh Orthopaedic Clinic in Raleigh, North Carolina.