Signs and Symptoms
- Thickening of the skin in the palm and /or fingers
- Fingers may be flexed (contracted) towards the palm
- May be unable to fully extend the fingers
- Generally not painful
Diagnosis
- Easy to diagnose by physical exam
Background
- A Dupuytren’s contracture is the name for a thickening of the fascia in the palm of the hand, which leads to a flexed posture of the main knuckle of the hand (MCP joint) and first joint of the fingers (PIP joint). It most often affects the ring finger and small finger. The palmar thickening is very subtle when it starts, but typically worsens over a period of several years, to the point where the fingers are “stuck” down in a flexed position. Dupuytren’s contractures are not inherently painful, however they can be bothersome in daily life and/or aesthetically undesirable. Treatment consists of a surgical release of the contracture with removal of affected tissue. It is not unusual for carpal tunnel or trigger finger to be present along with Dupuytren’s, so surgery may include addressing these as well.
- There are several techniques that may be used depending on your specific situation, however all surgeries aim to remove/release the affected tissue, and restore range of motion. The purpose of post-op hand therapy is to: ensure good wound healing, assist with swelling control, maintain the range of motion improvement that surgery achieved (preventing excessive/restrictive scar formation), and ultimately restore hand/finger strength and facilitate return to all previous activities.
*There is a lot of variability in the disease process and severity for each person, so there can be variability in how quickly each person recovers and what the end results look like. The information below is simply a general guide.
Treatment
Conservative (Non-Surgical)
These treatments do not remove the affected tissue
- Steroid Injection (can help with any associated pain)
- Xiaflex injection (essentially cuts the affected tissue in half to allow extension of the finger)
Surgery
This will remove the affected tissue so that recurrence of the problem is rare.
Hand Therapy
Week 1:
- The hand therapist or physician will remove the post-op dressings, and a removable custom-fabricated splint will be applied. The purpose of this splint is to keep your affected fingers straight in extension while they heal. This will preserve the finger extension that surgery achieved. It is extremely important to wear this splint at all times, until otherwise instructed. Length of time will vary based on the severity of your condition and your individual healing speed, but is typically at least 6-8 weeks.
- Your therapist will advise you on various gentle exercises that involve actively moving your forearm, wrist, hand, and fingers, plus specific movement patterns that facilitate full tendon and nerve gliding through your wrist.
- Your therapist will show you various ways to reduce the swelling, including elevation, active movement, and thermal modalities. You should have improved finger extension, though some stiffness may be present. Swelling will still be significant. Some redness and dryness around the incision is normal as the skin heals. Tenderness and soreness should improve rapidly after the first few days post-op, but it’s normal for movement to create some discomfort.
Weeks 2-4:
- At 10-14 days post-op, your sutures will be removed. At this time, your therapist will begin working to soften and mobilize the scar tissue that forms at incisions. Your therapist will also begin manual techniques to reduce swelling in the wrist and hand.
- Exercises will involve fine motor coordination/finger dexterity, active hand and finger movements, and gentle passive movements. Again, your therapist will instruct you on which movements are necessary and safe. Swelling should improve quite a bit during this phase, making it easier to form a full fist. Movement will feel more comfortable. By the time the sutures are removed, the top layer of skin will have healed, but deep tissue healing will continue for many weeks still.
**Therapy attendance during weeks 3-6 is EXTREMELY IMPORTANT, as rebound contractures often occur around week 3-4, and range of motion can be difficult to maintain in this period. It is essential that you continue to wear the extension splint.**
Weeks 4-6:
- If healing and range of motion are where they should be, gentle strengthening will be initiated. This will be progressively increased over the course of the next few weeks.
- Your therapist will closely monitor you during this phase to ensure your fingers are maintaining good extension, and that you are on track to meet your functional goals.
- Hand therapy will continue for aggressive scar management, as well as swelling reduction and exercise upgrades.
- Dupuytren’s scars are notoriously difficult. It will take time and effort to achieve a flat, mature scar. Your therapist will work with you to flatten and soften the scars as much as possible, and will show you techniques to utilize as part of your home program. Discomfort should be fully resolved by this point, and the superficial scars will be fading nicely by the end of 6 weeks.
Weeks 6-8:
- During the final week or so of formal therapy, hand and finger strength/endurance will be emphasized. Final functional goals will be dependent on the person’s age, prior level of function, and physical needs for daily life. The vast majority of swelling will have resolved by this point, but may continue to improve over the next 4-6 months.
- Assuming finger extension has not regressed at all, the extension splint will be weaned and discontinued per physician/therapist instructions. By therapy discharge, grip strength should be at least 50-75% of normal, and will continue to improve as time goes on. You can return to most activities by this time.
*This recovery timeline is generalized to apply to the average person. However, individual recovery time may vary depending on severity of pre-operative condition, prior level of function, age, health, lifestyle factors, tobacco/alcohol use, medical comorbidities, and other factors.
