Treatment Options for Dupuytren’s Contractures

Dupuytren’s disease is a chronic, progressive condition characterized by the thickening and tightening of the fascia in the palm of the hand. This leads to the formation of bumps (“nodules”) and bands (“cords”) that can cause fingers to bend toward the palm, often affecting the ring and little fingers most commonly. This can lead to significant deformity and disability of the hands.

Dr. Tony Trenga is a fellowship-trained hand surgeon at Hand to Shoulder Specialists of Wisconsin here to answer some common questions related to Dupuytren’s disease and its treatment options.

What causes Dupuytren’s disease?

The exact cause is unknown, but it is linked to genetic factors, particularly in individuals of Northern European descent. Other risk factors include age, gender (more common in men), and certain lifestyle factors like smoking, alcohol consumption, and heavy work with the hands. However, it can occur in all races and genders.

What are the symptoms of Dupuytren’s disease?

Dupuytren’s initially presents with small lumps (nodules) in the palm, which may thicken into cords over time. These cords can pull fingers into a bent position, limiting hand function. The cords and nodules are typically painless, and pain in or around cords and nodules may be from a different problem such as trigger finger or arthritis. In those with Dupuytren’s, similar contractures and deformity can be seen in the feet and penis and should be discussed with a podiatrist or urologist, if present.

What are the treatment options for Dupuytren’s?

Dupuytren’s is a genetic condition and there is no cure, but the contractures that form can be treated. In all forms of treatment, the contracture can recur and the length of time to recurrence is unpredictable.

Initially, Dupuytren’s is observed until the bands and resulting contracture make it difficult to perform daily activities, place your hand in your pocket, wear gloves, lay your hand flat on the table, or limit other activities.

3 main treatment options are available: surgery to cut out the fibrous cords (fasciectomy), percutaneous needle aponeurotomy, and collagenase (Xiaflex) injections.

Following all 3 treatments, a splint is worn at night for 3 months to keep the hand open.

• Surgery (palmar fasciectomy): Surgery involves incisions overlying the cord to excise them from the palm. In more complex contractures or revision cases, surgery may be the most reliable option. Compared to the other two options, surgery has demonstrated decreased rates of recurrent contracture within 5 years. The downside to surgery is increased pain and recovery time allowing the incisions to heal. This is done in the operating room with either a local anesthetic or general anesthesia.

  Minimally invasive, non-surgical options include: Percutaneous needle aponeurotomy and Xiaflex, which are performed in the office.

• Percutaneous needle aponeurotomy: The hand is numbed, and a needle is poked through the skin and used to make many small cuts in the cord along its length. Once the cord is cut, the finger is manipulated to tear the cord and straighten the joint. This is done in a single visit. Percutaneous needle aponeurotomy has higher recurrence rates than Xiaflex and surgery.
• Collagenase (Xiaflex) Injections: Xiaflex is a naturally occurring substance, collagenase, which selectively degrades the collagen in Dupuytren’s cords. If Xiaflex is chosen, authorization for the medication will be received from your insurance company prior to proceeding. Once approved, you will have an appointment to have the medication injected into the cord(s). The medication is then given 48-72 hours to break down the cord tissues. You will then return to the clinic 48-72 hours later for manipulation and straightening of the affected finger(s) under local anesthetic. Xiaflex has lower recurrence rates than percutaneous needle aponeurotomy. Complications, including tendon rupture, skin tears, vessel and nerve injury, and their frequency are similar between Xiaflex and needle aponeurotomy.

  After treatment for Dupuytren’s, a custom made splint is created by our Certified Hand Therapists here at HSSWI to wear at night and they will demonstrate exercises to perform to maximize your treatment and hand function.

What should I expect after Xiaflex injection?

After injection the hand will be bruised, sore, and swollen for several days. There may be some mild bleeding. These symptoms may be more severe if you are on a blood thinner. Heavy use of the hand is not recommended, doing so may lead to premature cord rupture. Other common side effects include swelling or pain in the lymph nodes (glands) in the elbow or armpit, itching, breaks in the skin, redness or warmth of the skin. Allergic reaction may occur. Elevating the hand above the level of the heart will help with pain and swelling. You may take Tylenol (acetaminophen) and Advil (Motrin/ibuprofen) as needed.

What should I expect at the manipulation visit?

The hand and fingers will be anesthetized with local anesthetic. After the hand is numb, the finger will be straightened, tearing the Dupuytren’s cord. Tearing of the skin overlying the cord is typical. When an acceptable correction of the contracture is achieved, the hand will be dressed and one of our Certified Hand Therapists will create a custom splint to keep the hand open. They will also demonstrate exercises to perform on your own to help with range of motion and stiffness.

How should I take care of a skin tear?

Skin tears are an expected result of the manipulation. Tearing of the skin will not affect the long-term outcome of your treatment. Some light bleeding is normal for a few days after manipulation. You should keep the wound clean and dry. You should cover the wound with gauze and change it daily until the bleeding has stopped; you may change it more frequently as needed. A regular Band-Aid may be used as well. You should wash your hand normally with soap and water; you may shower as normal; do not soak in a bath, pool, or hot tub.

When should I wear the splint?

You should wear the splint to bed every night for 3 months. This will help prevent the hand from closing down again. You may also wish to wear the splint during the day for the first few days while the swelling and soreness decreases. If wearing the splint during the day you should come out several times to perform your range of motion exercises.

Dr. Trenga is trained and proficient in performing Dupuytren’s surgery, percutaneous needle aponeurotomy, and Xiaflex injection. Based on the pattern of your cords and contracture, activity level, and other medical conditions, Dr. Trenga will come up with a treatment plan that is individualized to each patient. For assistance with any problem of the hand, wrist, elbow, or shoulder, call   or visit HSSWI.com to schedule an appointment today.

About Dr. Trenga:

Anthony P. Trenga, MD is a fellowship-trained hand surgeon specializing in all aspects of the hand, shoulder, and elbow. Originally from the east coast, Dr. Trenga, his wife, and two children have made Wisconsin home for more than half a decade. Dr. Trenga sees patients throughout the greater Milwaukee area.

About Hand to Shoulder Specialists of Wisconsin:

HSSWI, formerly Hand Surgery Ltd, is dedicated to treating all aspects of the upper extremity in Southeastern Wisconsin. All surgeons at HSSWI are fellowship-trained in hand and upper extremity surgery to provide comprehensive subspecialist care unique to the region.