[Noah930]

Both of the above pictures look like Dupuytren's disease. Often starts in the your 40s or 50s. Maybe with firm nodules in the palm, by the palmar flexion crease. Then it may start forming firm subcutaneous cords that run into the fingers. Ring finger is the most common, followed by the small finger and sometimes the middle finger. Rarely the index or thumb.

Somehow the fascia (connective tissue) in the palm gets turned on. We're not sure exactly why. It's genetic, linked to northern european ancestry. Usually it's not painful. There's not much you can do about it. It wasn't because of anything you did. It's not linked to any other diseases or medications. There's no medicine or therapy or splinting you can do to make it go away.

Rarely is it painful.

Usually we leave it alone until it starts causing flexion contractures in the fingers. That's when those Dupuytren's cords start contracting/shortening to the point where you can't straighten your finger, even by putting your hand on a flat tabletop. That's when we intervene, because that's when the function of the hand gets impacted.

Your traditional choice of intervention was to cut it out. Partial palmar fasciectomy. Cut out all the cords and nodules, to allow the finger(s) to straighten once again. It's a surgery.

Another option is just to slit the contracting cords to straighten the finger. Instead of a full surgery, we just numb up the palm/finger(s) by some local injections. Then we take a hypodermic needle, and use the tip of it to cut the cords. The tip of a needle isn't perfectly round, like the end of a cylinder. Rather, the tip of a hypodermic needle is a little beveled, like a knife tip. Imagine a cone with its tip lopped off on a diagonal cut. So we use that beveled tip to our advantage. We insert the tip of the needle through the skin (which has been anesthetized), and then swish it back and forth to use the tip to cut through the constricting cord. Do that at a few levels, and then that should allow the finger to extend/straighten back out. The "stuff" of the Dupuytren's is still there in the hand, but the finger can now straighten out.

The benefits of a needle aponeurotomy: It's not a surgery, so less recovery, cheaper. Can be done in an office, instead of an OR. No real post-op wound.

The negatives of a needle aponeurotomy: It leaves the Dupuytren's disease behind in your hand, so recurrence rate is greater. There are some situations in which you can't do it, such as if the Dupuytren's cords spiral around digital nerves and arteries. Most docs aren't willing to do it if you've had previous Dupuytren's surgeries on the fingers/hand, as the anatomy (and location of those nerves and arteries) may no longer be in expected locations. Possibility of nerve damage (because this is a bit of a blind procedure), which is usually permanent if you get it.

The 3rd option is a collagenase injection. Maybe around for the past 15 years or so. Better living through science, right? Inject an enzyme to dissolve the collagen cord. Similar concept to the needle aponeurotomy. Use a collagenase to dissolve a section of the cord, to allow the finger to straighten. The benefits: Just one injection (actually 3 per the technique, but they're given at the same site at the same time). Then you come back to the office in 2 or 3 days, and the doc stretches out the finger to pop the weakened Dupuytren's cord. The negatives: Cost. The company that manufactures the medicine charges about $2500 per shot. Your insurance may or may not cover that cost. The average patient requires 1.4 injections, per the literature. Meaning, some need one shot, some people need two shots. Factor that into the cost calculations. The collagenase doesn't attack just the Dupuytren's cords, but all connective tissue in the area. So it's normal to get localized or palmar bruising and swelling. There is theoretic risk of dissolving the underlying flexor tendons (that's a disaster if it happens), but fortunately it's pretty rare.