Joey Wahler (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

It's a condition of the hand that can be very debilitating. So, we're discussing Dupuytren's contracture, also called Dupuytren's disease. Our guest, Dr. Jimmy Dang. He's an Orthopedic Surgeon for Skagit Regional Health, specializing in hand surgery.

This is Be Well with Skagit Regional Health. Thanks for listening. I'm Joey Wahler. Hi, Dr. Dang. Thanks for joining us.

Jimmy Dang, DO: Thanks for having me, Joey.

Joey Wahler (Host): Appreciate you hopping aboard. So first, what exactly is Dupuytren's disease and what causes it in the first place?

Jimmy Dang, DO: Dupuytren's disease is a disease of the fibrous tissue in the palm of the hand. It involves tissue called the palmar fascia. This is a similar tissue to the fascia in the arch of your foot. Most people are probably more familiar with the plantar fascia. In the palm, it starts and goes towards the finger and kind of looks, I always kind of compare it to a spider web.

It extends down to the fingers. You have some fibers going across the palm, and then some going towards the skin and then deep around the tendons, the nerves and the arteries. The normal function of the fascia is to cover important structures and also stabilize the skin. With this disease, the tissue thickens and forms diseased tissues, and the two types of diseased tissues that patients normally see are what we call nodules or cords.

The nodules are round in nature and sit in the palm of the hand. Oftentimes, patients can confuse this with either ganglion cysts or calluses. They tend to be very superficial, just underneath the skin. The other things that patients notice are cords, which are rope-like structures and these are often mistaken for tendons.

Joey Wahler (Host): And so what brings this about?

Jimmy Dang, DO: For as long as we've known about Dupuytren's, we don't really understand what causes it. And we also don't have a cure for the disease. What we try to do is provide ways to improve the symptoms. We do know there are certain factors that predispose patients to have Dupuytren's, and the strongest linkage is really hereditary. For patients that have Northern European descent, these are strong family predispositions. It used to be called the Viking's disease. It is common in men. It's common as you get older. And as patients get older, the distribution between men and women starts to even out.

Joey Wahler (Host): Interesting. And so what age range typically would we find this usually starting to affect people?

Jimmy Dang, DO: Around, early to late 40s.

Joey Wahler (Host): Okay. And what symptoms most typically would a person see?

Jimmy Dang, DO: Aside from the nodules and cords forming, these can also create contractures from the cords thickening up. And oftentimes, patients will complain that they cannot fully extend their fingers, so they have difficulty with tasks where they have to place their palm flat; such as doing push-ups, doing yoga poses, they have difficulty getting their hands into pockets or gloves, sometimes it's even awkward even shaking hands.

I've had a few patients even complain that when they're washing their face that the finger that's contracted down often is poking them in the eye.

Joey Wahler (Host): Wow. Now does it typically affect one or both hands? And if you get it in one, how likely are you to eventually have it in the other?

Jimmy Dang, DO: It's hard to predict, whether it'll be unilateral or bilateral. It's most common in the ring finger followed by the small finger. It can happen, I've seen some patients just have it on one finger and on others almost every finger in the hand, including other areas of the body.

Joey Wahler (Host): So there's nothing then that people can do on their own to ward this off?

Jimmy Dang, DO: Unfortunately, there's not. There's a lot of research going into this right now, but we still don't really have a cure for it. People have talked about splinting or trying stretching, but it really won't slow down the disease. And in some patients, the disease starts off first with a nodule, and it never progresses. Or in others, it's a very slow process. So it's hard to kind of predict whether the treatment is really effective, but there's really no evidence that splinting, stretching or other things will slow it down. In Europe, they are doing radiation, specifically low-dose radiation to the nodules and cords to see if this will slow down the disease process.

There are unknown side effects of radiation long-term with this type of treatment, so it's not as common here in the United States.

Joey Wahler (Host): So what are the treatment options that are most commonly used for this?

Jimmy Dang, DO: There are a lot of different treatment options. The biggest thing when it comes to this disease is really just educating the patients on understanding when to seek treatment. Again, when they have just nodules and cords, but really no contractures, we just have to wait and see if the contractures occur and start to affect their daily use of their hands.

Sometimes the nodules themselves can be painful. In those instances, we can do a steroid injection into the nodule to help with some of the pain and discomfort. But this typically doesn't do anything to change the characteristic of the nodule itself, it'll still stay there. Once you explain this to patients, most people just leave the nodules alone.

When it starts to create contractures of the fingers, where the fingers are starting to get pulled down towards the palm of the hand, then we have various treatments for this. Traditionally, the treatment would be going in and having an open surgery, which is a large incision where you would take out all the tissue.

It does well to help the patient extend the finger and hopefully reduce the occurrence. But no matter what treatment you choose, there's always a risk of recurrence. It's not necessarily a cure for the disease. This typically entails large wounds and extensive dissection and a long recovery.

So there are two other types of treatments you can do in the office, which I prefer to do if it's, if we're able to do those procedures. The first is a percutaneous needle release. And I typically like to do these for contractures that involve the MCP joints, which is the most proximal joint within the base of the finger. With these types of contractures, you can numb the finger up in several spots, right overlying the rope-like structure and use a small needle, kind of like a knife, to break up the cord.

What I'm trying to do is fray the rope-like structure in a few spots, and then stretch out the finger to straighten it up. Again, the goal is not to remove the tissue but to break the rope or cord up so the finger can be extended. And this is done manually. The other option you have is a medication called XIAFLEX.

This has been a medication now that's been used probably over the last 10 to 15 years. It is a collagenase, which breaks down the type of collagen within the cord. You come in for a day, the tissue gets injected, and then a couple of days later, the patient comes back and the finger gets numbed up and stretched out.

So in the first case where we're doing the percutaneous needle release, you're manually breaking up the cord. Whereas with the XIAFLEX injection and the manipulation, you're breaking it up chemically.

Joey Wahler (Host): A couple of other things. First, to be clear, it seems you're saying that you may see a physical difference in your hand with the things you've described, but you might not necessarily have discomfort from it. Yes?

Jimmy Dang, DO: Correct.

Joey Wahler (Host): And so if you are someone that lets it go, doesn't see a doctor, is there a danger in having it go untreated?

Jimmy Dang, DO: There is a danger when you let the contractures go for too long, especially for the PIP joint, which is the middle joint to the finger. This joint doesn't like to be in a flexed position for too long. If you leave it for too long, even if you remove the tissue or break up the tissue, then you're still going to have difficulty extending the finger.

Joey Wahler (Host): Earlier, doctor, you compared it to plantar fasciitis, which I know can be also very debilitating and can be something that people have difficulty shaking. It seems like there's a similarity there. Is there not, in that once you get it, it never really goes away.

Jimmy Dang, DO: So it's a very similar tissue to the plantar fascia and you can get the same type of nodule within the arch of the foot, within the plantar fascia. And in that case, there are nodules, and it's considered, Leiderhosen's disease. Another common place that you can also get the contractures, is in the penis, for men. And with the feet, it tends to not cause contractures, but whereas for the penis, this can lead to contractures. And this is considered Peyronie's disease. Another common area that you can get these nodules is actually at the top of the knuckles to the fingers.

Joey Wahler (Host): I think that sounds like a subject for a whole other podcast, yes?

Jimmy Dang, DO: Yes, it's a very interesting topic, with a lot of research behind it, but still a lot of unknowns.

Joey Wahler (Host): And speaking of unknowns, you led me in beautifully because I wanted to ask you next, how frustrating is it for you as a physician to have a condition that is so somewhat mysterious in terms of not knowing the exact cause and not usually being able to offer a concrete diagnosis. That's kind of unusual in medicine today, isn't it? This is kind of a throwback condition in that respect.

Jimmy Dang, DO: I don't look at it as frustrating. I look at it as somewhat of a challenge and for the procedures to improve the patient's extension to their fingers from this disease, a lot of those procedures are very successful. They don't change the fact that the symptoms can still recur, but to achieve the extension of the finger and make patients functional, it works really well.

One of my favorite procedures actually is the percutaneous needle release to do in the office, because you can have a patient come in with an 80-degree contracture to the finger. And 10 minutes later, they're walking out with a straight finger. It's a very gratifying procedure to do.

Joey Wahler (Host): Wow. Okay. So great to hear you putting a positive face on things. I'm sure our listeners would agree. And speaking of which, in summary, how would you sum up what people can expect about the quality of life they're in for if they have Dupuytren's disease and it's properly addressed in a timely manner?

Jimmy Dang, DO: Having Duputren's disease shouldn't really affect patient’s functions or quality of life, as long as they understand when to get things treated. I think with what we have out there for the treatments now, if we catch it early, we can prevent the severe contractures from forming and leading to more disability.

Joey Wahler (Host): Gotcha. Welcome news indeed. Well, folks, we trust you're now more familiar with Dupuytren's disease. Dr. Jimmy Dang, thanks so much again.

Jimmy Dang, DO: Thanks for having me.

Joey Wahler (Host): Absolutely. And for more information, please visit SkagitRegionalHealth.org. Again, that's SkagitRegionalHealth.org. Now, if you found this podcast helpful, please post it on your social media.

I'm Joey Wahler. Thanks again for listening to Be Well with Skagit Regional Health.