About Dupuytren’s contracture

Dupuytren’s contracture is an uncommon hand deformity in which the connective tissue under the skin of your palm contracts and toughens over time.

Knots of tissue form under the skin, eventually forming a thick cord that can pull one or more of your fingers into a bent position. Once this occurs, the fingers affected by Dupuytren’s contracture bend normally but they can’t be straightened completely, making it difficult to use your hand. Dupuytren’s contracture can complicate everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands.

Dupuytren’s contracture is rarely painful, though sometimes the bumps of tissue on your palm can be sensitive to touch. Various treatments are available for Dupuytren’s contracture to slow its progression and relieve your symptoms.

Symptoms

Signs and symptoms of Dupuytren’s contracture may include:

  • At first, a thickening of the skin on the palm of your hand. As the condition progresses, the skin on the palm of your hand may appear dimpled.
  • Formation of a firm lump of tissue on your palm. This lump may be sensitive to the touch, but usually isn’t painful.
  • In later stages, formation of cords of tissue form under the skin on your palm that may extend up to your fingers. As these cords tighten, your fingers may be pulled toward your palm, sometimes severely.

Which fingers are most likely affected
Dupuytren’s contracture most commonly affects your ring finger and your little finger, though your middle finger also may be involved. Only rarely are your thumb and index finger affected. The condition often affects both hands, though one hand is usually affected more severely than the other.

Slow progression
Dupuytren’s contracture typically progresses slowly, over several years. Occasionally it can develop over weeks or months. In some people it progresses steadily, and in others it may start and stop. In a few cases, Dupuytren’s contracture may get better without treatment.

Some doctors prefer the term “Dupuytren’s disease,” rather than “Dupuytren’s contracture,” because some people don’t experience the bent fingers — the contracture part of the disease.

Although the precise cause of Dupuytren’s contracture hasn’t been identified, a number of factors are believed to increase your risk of the disease, including:

  • Family history. A propensity to develop Dupuytren’s contracture may be passed on through families, though researchers haven’t identified a gene mutation that might identify who’s at risk.
  • Tobacco and alcohol use. Smoking is associated with an increased risk of Dupuytren’s contracture, perhaps because of microscopic changes within blood vessels caused by smoking. Alcohol intake also is associated with Dupuytren’s, although not everyone with Dupuytren’s abuses alcohol.
  • Diabetes. People with type 1 diabetes or type 2 diabetes have an increased risk of tender tissue lumps on the palms of the hands, but the condition is generally mild and progresses very slowly. Fingers usually don’t become contracted.

Diagnosis

To make a diagnosis, your doctor will likely conduct the following tests:

  • Physical exam. Your doctor will both look at and feel your hands to identify the characteristic nodules or cords in your palms or fingers. You’ll also be asked questions about your signs and symptoms. Your doctor will want to know whether you’re having difficulty using your hands; for instance, are you able to extend your fingers to put on gloves or to shake someone’s hand.
  • Tabletop test. In this simple test, you place your hand palm-side down on a table. If you can get your hand flat, you don’t have a contracture. If you can’t get your hand flat against the table, then you do have a contracture.

Your doctor usually doesn’t need further tests to make a diagnosis. However, he or she may order other tests to rule out associated conditions, such as diabetes.

Complications

Dupuytren’s contracture can make it difficult to perform certain functions using your hand. Because the thumb and index finger aren’t usually affected, many people don’t experience much inconvenience or disability with fine activities such as writing. But as Dupuytren’s contracture progresses, it can limit your ability to fully open your hand, and make it difficult to grasp large objects or to get your hand into narrow places.

People with Dupuytren’s contracture may experience other connective tissue disorders, including:

  • Plantar fibromatosis. Sometimes called Ledderhose disease, plantar fibromatosis occurs on the sole of the foot and is similar to Dupuytren’s contracture. Lumps and cords of tissue form on the sole, and the toes may be pulled down, making it difficult to walk. This rare complication is most common in people with a severe familial form of Dupuytren’s contracture called Dupuytren’s diathesis.
  • Peyronie’s disease. This rare tissue disease affects the penis. Scar tissue forms under the skin of the penis, causing a bend in an erect penis. This complication is rare and may also be a risk for people with Dupuytren’s diathesis.
  • Knuckle pads (Garrod’s nodes). Pads of tissue may form on the tops of your fingers, over the middle knuckle (proximal interphalangeal joint). Knuckle pads are more common in people with Dupuytren’s diathesis.

Treatment

If the disease progresses slowly, causes no pain and has little impact on your ability to use your hands for everyday tasks, you may not need treatment. Instead, you may choose to wait and see if Dupuytren’s contracture progresses.

Your doctor may ask you to come in for checkups every few years, usually to conduct the tabletop test and monitor any progression of Dupuytren’s contracture in your hands. Or, your doctor may ask you to try the tabletop test at home on your own and make an appointment if you notice your condition is worsening.

On the other hand, early detection and treatment of Dupuytren’s contracture may slow the disease’s progression and reduce your risk of problems later on. The more severe the deformity, the less effective treatment is likely to be.

Treatment options for Dupuytren’s contracture may include:

Nonsurgical options
Nonsurgical therapies include:

  • Steroid injections. Injections of a steroid medication into the early-stage bumps of tissue may lead to softening and flattening of the bumps and may reduce tenderness. Several injections may be needed to see an effect. You may need additional injections as time goes by.
  • Radiation therapy. Some preliminary studies show that in the early stages of Dupuytren’s contracture, when connective tissue cells are multiplying in your hand and haven’t yet begun the scarring process, radiation therapy may help slow the disease process. More research is needed to evaluate the long-term effects and risks of this type of therapy.
  • Needle aponeurotomy. This minimally invasive procedure is sometimes used to help straighten fingers bent by Dupuytren’s contracture. The technique uses a needle to puncture and “break” the cord of tissue that’s contracting a finger, allowing the finger to be straightened again. Needle aponeurotomy is generally done in the doctor’s office. It has few complications and is less expensive than surgery, but requires a doctor experienced in the technique. Contractures often recur but can be treated in a similar fashion.

Researchers are investigating enzyme injections for Dupuytren’s contracture. Preliminary results have shown that enzymes injected under the skin can break down the knots and cords of tissue. Ongoing clinical trials will show whether this can prevent Dupuytren’s contracture from recurring. Until then, enzyme injection is considered experimental and is available only at a few medical research facilities.

Surgery
Surgery for Dupuytren’s contracture is reserved for people who experience disability from the disease. Although surgery can improve hand function, it doesn’t necessarily prevent a recurrence of Dupuytren’s contracture. Sometimes the disease returns to the same spot on the hand, other times it reappears in other places on the hand.

Which type of surgery you undergo for Dupuytren’s contracture depends on factors such as your age, the degree of contracture in your fingers, and the condition of the skin and bones of your hand. Types of surgical procedures include:

  • Releasing cords of tissue (subcutaneous fasciotomy). Subcutaneous fasciotomy is similar in intent to a needle aponeurotomy, but uses a scalpel instead of a needle to sever the cords of tissue under the skin. Both needle aponeurotomy and subcutaneous fasciotomy are used in people who can’t undergo more extensive surgery or prefer to avoid the risks of an extensive surgery. As with needle aponeurotomy, Dupuytren’s contracture may recur after subcutaneous fasciotomy. The technique works best when Dupuytren’s contracture is limited to the palm of the hand because the procedure can injure nerves when it’s done in the fingers.
  • Partial tissue removal (partial fasciectomy). Partial fasciectomy is the most common procedure for late-stage Dupuytren’s contracture. During partial fasciectomy, the surgeon removes as much of the diseased tissue as possible. Surgeons can’t always remove all of the diseased tissue because it can be difficult to identify tissue in very early stages of the disease. Diseased tissue may also attach to the skin, making it difficult to remove. For this reason, it’s common for Dupuytren’s contracture to recur after partial fasciectomy, though it’s usually less severe and may not require additional surgery.
  • Complete tissue removal (complete fasciectomy) with skin grafting. Younger people and those with the highest chance for recurrence might consider complete fasciectomy to completely remove the tissue on the palm of the hand. The diseased tissue in Dupuytren’s contracture usually attaches to the underside of the skin on your palm and fingers, so it may be necessary to remove the skin in order to completely remove the tissue. The removed skin can be replaced with skin from another part of your body. Recurrence is rare after complete fasciectomy. However, this procedure carries the highest risk of complications, including finger stiffness or an inability to bend the fingers. This can be more disabling than the original condition.
  • Finger amputation. Some people experience recurrent Dupuytren’s contracture despite multiple surgeries and may consider amputation. Amputation surgery is most commonly used to remove the little finger.

All surgeries carry risks of bleeding and infection. Be sure to discuss any concerns with your doctor.

Physical therapy
Depending on the extent of your surgery, you may require therapy to help speed your recovery after the procedure. Less invasive procedures may require four to six weeks of therapy, and more invasive surgery could require three to six months of therapy. Therapy usually involves exercises to improve the ability to move your fingers.