Disease Description (Causes and Symptoms)
- Definition: A chronic, progressive fibrotic disease (Dupuytren's contracture) in which the palmar fascia (palmar aponeurosis) thickens and forms fibrous bands (cords) due to fibrous and myofibroblastic proliferation, causing primarily the fourth and fifth fingers to gradually bend and become unable to straighten.
- Causes and pathophysiology: The exact cause is unknown, but the main mechanisms are genetic predisposition, increased myofibroblast activity in the fibrotic response, and accumulation of collagen (especially type III). Nodules and cords form in the palmar fascia, causing flexion deformities of the MCP and PIP joints.
- Risk factors: Male sex, middle and older age (usually in the 50s–70s), family history, diabetes, excessive alcohol use, epilepsy (an association with anticonvulsant treatment has been reported), and reported associations with smoking, epilepsy, and liver disease.
- Main symptoms: Firm nodules (lumps) or depressions in the palm, formation of bands (cords) extending toward the fingers, and gradual flexion of the fingers (especially the fourth and fifth fingers). Pain is usually mild or absent, but pain may occur due to nerve compression or other causes. Bilateral involvement is common. Functional limitations can make daily activities difficult.
Treatment Methods and Precautions
- Conservative management
- When symptoms are mild or there is no functional limitation, observation (regular examinations and photographic records).
- Physical therapy, finger stretching, and nighttime extension splinting (effectiveness is limited and should be individually applied according to symptoms and function).
- Nonsurgical procedures
- Percutaneous needle fasciotomy (needle aponeurotomy): A method of cutting the cord with a needle without an incision. Recovery is rapid and short-term functional recovery is possible, but the recurrence rate is relatively high.
- Collagenase (Collagenase clostridium histolyticum) injection (when available): After injecting the enzyme into the cord, the cord is ruptured through external manipulation. Recovery is faster than with surgery, but cost, availability, and potential complications should be considered.
- Surgery
- Under local or general anesthesia, local excision (fasciectomy), partial excision, or, when skin damage is severe, skin excision plus skin grafting (dermofasciectomy). The surgical method is determined according to the extent of the lesion, degree of joint involvement, and the patient's condition.
- Surgical complications: Wound infection, bleeding, nerve or vascular injury, delayed wound healing, joint stiffness, persistent pain, and skin defects at the surgical site.
- Recurrence: Recurrence is possible even after surgery. Although reported recurrence rates vary according to the treatment method and follow-up period, the literature reports a range of 20–60% (approximately 50% was mentioned in the provided materials).
- Rehabilitation after surgery
- Wound care, early range-of-motion (ROM) exercises, hand rehabilitation (occupational therapy), and nighttime splinting when necessary.
- Precautions and self-management
- Because the disease progresses slowly, discuss treatment options when there is an early impact on function.
- Management of associated factors such as diabetes, alcohol use, and smoking is recommended (particularly, diabetes control helps with overall surgery and healing).
- Strong passive extension or attempting procedures yourself can cause injury and should be performed only under professional guidance.
- Consult the medical staff about instructions before and after procedures or surgery, including whether to stop or continue medications and how to care for the wound.
Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)
- Items to bring to the visit
- A list of medications and supplements currently being taken (including anticoagulants), and a history of allergies
- Copies of previous test results (blood tests, imaging, surgical records, etc.) and referral letters or medical certificates from other hospitals, if available
- When symptoms began and how quickly they have progressed (photographs comparing different time points can be useful)
- A list of daily activities made difficult by the symptoms (e.g., buttoning clothes, putting on gloves)
- Information to record and bring
- Which hand is affected (right/left), which fingers are affected (e.g., fourth/fifth fingers), and whether both hands are affected
- Whether pain is present and whether neurological symptoms (tingling or decreased sensation) are present
- Family history (bent fingers or previous surgery)
- History of previous related treatments (injections, needle fasciotomy, or surgery), including their effects and side effects
- Examples of questions to prepare before asking during the outpatient visit
- When did the finger(s) start becoming unable to straighten (how long ago)?
- Which activities are most difficult?
- Is there pain, tingling, or altered sensation?
- How does this affect daily life (work or hobbies)?
- Taking photographs during medical visits: Photographs of the hand in an open position and with the fist clenched can help with diagnosis and follow-up.
Examples of General Questions to Ask the Doctor
- What is the current severity of my hand condition (moderate/severe), and do I need treatment immediately?
- What are the advantages and disadvantages of each treatment (observation/needle fasciotomy/collagenase injection/surgery), and which option is recommended in my case?
- What is the recovery period for each treatment, and when can I return to daily activities?
- What are the main complications of the surgery or procedure, and how likely are they to occur?
- What is the likelihood of recurrence, and how would it be managed if it recurs?
- How do diabetes, epilepsy, and alcohol use affect my treatment outcome? What lifestyle changes should I make?
Examples of Condition-Specific Questions
- For my finger angles (e.g., PIP 30°, MCP 40°), which is more advantageous in the long term: needle fasciotomy or open surgery (fasciectomy)? Can you tell me the differences in recurrence rates and complications using numbers (estimated probabilities)?
- I previously had an injection (or needle fasciotomy) in the same area, but it recurred. If you recommend surgery this time, will skin grafting (dermofasciectomy) be necessary if a skin defect is expected, and what are its advantages and disadvantages if it is needed?
(Making a note of the questions above before the visit can make the consultation go more smoothly.)