History
Hand Section of drdcunningham.com
| Definitions
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Dupuytren’s disease is an abnormal thickening of the fascia (the tissue between the skin and the tendons in the palm) that may limit movement of one or more fingers. In some patients, a cord forms beneath the skin that stretches from the palm into the fingers. The cord can cause the fingers to bend into the palm so they cannot be fully straightened (see Diagram 1). Sometimes, the disease will cause thickening over the knuckles of the finger. It can also occur in the soles of the feet. |
| History
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Dupuytren was born in central France. He was kidnapped as a boy by a rich woman from Toulouse on account of his good looks. He was taken to Paris and educated, but endured great poverty throughout his studies. Dupuytren became Surgeon in chief at the Hotel Dieu in Paris and worked tremendously hard and became very rich. He was described as an unpleasant person to met, yet his work was delightful to read. He was characterised as "First among surgeons, Last among men". He was an accurate clinical observer with a great interest in pathology. Dupuytren's name is most associated with the contracture of palmar fascia and a particular ankle fracture that he described. He performed his first palmar fasciotomy on a coachman at the Hotel Dieu in 1831. He wrote on many subjects, including congenital dislocation of the hip, the nature of callus formation, subungal exostosis, the Trendelenburg sign, tenotomy in torticollis and he differentiated osteosarcoma from "spina ventosa". He insisted that on his death that his post-mortem be performed in front of his own medical staff and published in the local weekly journal. |
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| Treatment
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Treatment in the early, nodular stages of Dupuytrens disease is usually a watch and wait situation. There is no known way to alter the course of Dupuytrens, thus it is best to just stay on top of it. Patients are usually seen every several months to have the extent of the condition regularly monitored. Surgery is indicated when Dupuytrens causes contractures to form. Contractures are tightenings within the tissues that cause the fingers to bend, and hold the fingers in this position. Depending on the joint that is held in the contracted position, a surgical decision can be made. When you make a fist, you have three knuckles (joints) that are apparent in each finger. The surgical procedure is known as a fasciectomy, where segments of the palmar fascia are removed. This procedure is only done if contractures have already formed. However, if there are contractures, it is important to consider early surgery as too much delay can necessitate a larger procedure where skin is also removed to repair the contracture.
The problem with surgery is that Dupuytrens tends to envelop adjacent structures, most importantly the small nerves in the hand and fingers. Dissection is slow and tedious, and injury to the nerves is a potential complication. Furthermore the contractures may often return months or years after surgery. Physical therapy and splinting after any surgical procedure is essential, as without such treatment the contracture will almost always recur. As stated above, there is a significant chance that Dupuytrens disease will come back. Therefore, the greatest complication is that the condition will return. Also concerning, is that the Dupuytren's contracture can envelop the small nerves of the hand and fingers. These nerves can be easily damaged during surgery. |
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Dr. David Cunningham 3535 blvd. St Charles,
Kirkland,Qc. H9H 5B9 514 694-1425
