Dupuytren’s disease is condition in which hard cords form on the palmar surface of the hand causing the fingers to curl into the palm. It is more common in men and in the over 60 year old age group and people with a Northern European ethnicity. The cause is predominantly genetic hence there tends to be strong family history but it is also associated with diabetes and excess alcohol consumption.
Patients may initially notice small nodules in their palm which can be tender to touch, followed by thickening of the palm skin. As the condition progresses the fingers curl into the palm making placing the hand flat on a table or putting hands into one’s pocket more difficult.
Diagnosis is entirely clinical meaning it is made on the basis of how the condition has progressed, your medical and family history and most of all from examination of the hand. No tests are necessary.
There is at present no cure for this condition. All treatments aim to control the symptoms. In the very mild cases, a simple night splint to stop the fingers bending at night may help. In moderate to severe cases we recommend surgery ranging from the simplest option needle fasciotomy to complex surgery called fasciectomy and dermofasciectomy. In select patients treatment with collagenase injection (Xiapex©) may be appropriate. This is an injection of an enzyme which breaks down the abnormal Dupuytren’s tissue. Which procedure is best for you depends on your preference, your medical history and the severity of disease.
Needle fasciotomy is carried out under local anaesthesia. A small needle is used to scratch the tight contracted tissue until it is released. The advantage of this technique is that it is quick and recovery usually takes no more than a few days. However, it may not fully correct the contracture and repeated treatments may be required.
Formal surgical removal of the affected tissue can be performed under local, regional (anaesthetising the arm with the patient awake) or general anaesthesia. It involves making carefully planned incisions on the palm and hand and removing the affected tissue taking care not to damage the underlying structures. Sometimes a skin graft might be needed to cover skin defects or to reduce the chance of disease coming back. After the operation, patients go home on the same day with a plaster that will be changed to a removable splint after a week or so. It is advisable to wear the splint at night for 3 months. The type of surgery will govern the speed of post-operative recovery.
Incomplete straightening of the fingers, delayed healing and stiffness are common after surgery. The disease may develop in parts of the hand that have not been operated and it may return at the site of surgery although usually not for many years. Temporary numbness of the fingers is common but occasionally it can be permanent. Rarely postoperative pain can take several months to subside.
Mucous cysts are ganglia (harmless fluid filled sacks that arise from joints) of the fingertips. The underlying cause is wear and tear of the involved joint. Ganglia can develop in the hands, wrist and less so the feet.
Patients may complain of pain if the mucous cyst has developed as a result of osteoarthritis in the joint. Furthermore the cyst can put pressure on the nail and alter its growth causing ridging of the nail. Sometimes they can become very large, unsightly and burst intermittently causing a discharge and risking infection.
An x-ray will be taken to show the location of ‘osteophytes’ or spikes of bone that are the cause of the cyst and need to removed at surgery to prevent the cyst returning.
If the cyst is small and is not causing any problems it can be left alone safely. For mucous cysts causing pain or problems, surgery is the mainstay of treatment.
The surgery can be carried out under local or general anaesthesia as a day case. An incision is made on the back of the finger to remove the cyst and to remove the osteophytes. Often a ‘flap’ is required to close the wound which means a longer scar. A finger dressing will be applied. Light duties and driving can commence in 1to 2 weeks, heavy manual labour 4 weeks after the operation.
Wound infection, regrowth of the cyst and damage to the tendon are potential complications of the surgery.
Ganglions are the most common soft tissue swelling of the hand and wrist. They contain a jelly like substance and are harmless. The majority develop at the back of the wrist, with a smaller number on the front of the wrist. Ganglions of the joint near the fingertip are called mucous cysts. Ganglions can also occur in feet and ankles.
They usually present as round or oval shaped lumps that can be compressed. Normally they are painless but rarely can cause irritation of a nerve leading to pain, tingling and muscle weakness.
A careful history and examination is usually enough to make a diagnosis. An x-ray might be needed to check for evidence of arthritis. If the diagnosis is uncertain an ultrasound scan or an MRI might be needed.
Most ganglions can be left alone without any harm. Some larger ones can be decompressed with a needle. If very large, painful or affecting function (such as work, wearing a wrist watch) surgical excision can be undertaken.
This can be performed under regional or general anaesthesia as a day case. The incision size and site will be governed by the location and size of the ganglion. The hand is dressed with a bulky bandage, which is then replaced with a small sticky plaster. Light duties and driving can commence one week, light manual labour four weeks and heavy manual labour six weeks after the operation.
Complications are uncommon but wound infection, poor scarring and return of the ganglion can occur. Nerve damage and complex regional pain syndrome occur rarely.
Tendons are cables pulled by muscles to move joints. . In the fingers there are several bands (called pulleys) that keep the tendons close to the bones to improve the mechanics of movement. Sometimes due to a formation of nodule or a thickening of the pulley, the tendons get stuck, or trigger, as they pass through the thickened pulley. This condition is more common in diabetic patients.
Patients typically complain of a their finger becoming stuck when they make a fist and the finger then “snapping” back to its normal straight posture either on its own or with gentle help. Sometimes more than one finger can be triggering at the same time.
A careful history and examination will be all that is required to make a diagnosis.
Sometimes the triggering can resolve by itself. If painful, simple analgesia may help. When symptoms do not resolve on their own patients can be treated with either an injection of a steroid into the affected area, or surgical release of the pulley in the palm. If after two injections of steroid the triggering is not resolved or comes back, further injections are unlikely to help.
The surgery can be performed under local or general anaesthesia as a day case. A small incision is made in your palm to blend in with the natural palm creases. The pulley is released relieving the tightness around the tendon. The hand will be bandaged with bulky dressing which is then replaced with small sticky plaster after 48 hours. Normal usage of the hand is encouraged pain permitting, with light duties and driving one week after surgery, light manual labour two weeks and heavy manual labour 4-6 weeks after surgery.
Wound infection and poor scarring are the commonest complications but rarely prolonged pain can be a problem.