Dupuytren’s contracture (sometimes referred to as Dupuytren’s disease) is a disabling hand condition in which connective tissue under the palm thickens and tightens.
This thickening and tightening of the palmar fascia (connective tissue) leads to one or more fingers being pulled in towards the palm. The pinky, ring, and sometimes middle finger are the digits most commonly affected.
These contracted fingers are an acquired hand deformity, as people with Dupuytren’s lose their ability to extend their fingers fully without medical intervention.
Dupuytren’s contracture is named after Guillaume Dupuytren. Guillaume was the French surgeon who described Dupuytren’s contracture’s internal disease process and performed the first successful Dupuytren’s contracture reduction operation in 1831.
Dupuytren’s contracture usually develops very slowly over time. It could take several years for a patient to begin to present symptoms commonly associated with Dupuytren’s contracture.
This condition begins with the skin on the palm thickening. With time, the skin may start to dimple or pucker. As Dupuytren’s advances, masses (nodules) begin to form under the palm. These masses aren’t typically painful, but they might be sensitive or tender. These symptoms mark the beginning of Dupuytren’s contracture.
The hand deformity happens in the advanced stages of the disease when cords form under the palm and extend out into the fingers. At this point, the cords begin to contract and draw the fingers in towards the palm.
This condition is marked by the patient’s fingers being frozen in the contracted position; they cannot straighten them. Daily activities that may be interrupted by the affliction of this hand deformity include:
While researchers still haven’t pinpointed the exact cause of Dupuytren’s contracture, they have identified some modifiable and non-modifiablerisk factors associated with developing Dupuytren’s contracture.
Dupuytren’s contracture is most common amongst white men who are 50 or older and of Northern European or Scandinavian ancestry. Only approximately five percent of the United States population experiences Dupuytren’s contracture. In the United Kingdom, that prevalence rises to twenty percent amongst people aged 65 or older.
Northern Europe includes Great Britain, Ireland, Scotland, France, and the Netherlands. Scandanavia includes Sweeden, Norway, and Finland.
Men develop Dupuytren’s contracture at a rate much higher than women. The reason for this difference in the rate of occurrence between the sexes is unknown.
A genetic predisposition is a huge factor in whether someone is likely to develop Dupuytren’s contracture. Sixty to seventy percent of people who experience Dupuytren’s contracture have a family history.
Smoking, especially more than a pack a day, puts people at increased risk of developing Dupuytren’s contracture.
Dupuytren’s contracture also more often affects thin people, with a BMI (Body Mass Index) lower than the population average.
Some research has shown that alcoholics have a higher chance of developing Dupuytren’s than the average person.
Several health statuses and conditions are linked with increased occurrence of Dupuytren’s contracture. Most of these health risk factors are part of a patient’s personal medical history and are non-modifiable.
Health risk factors of Dupuytren’s contracture include:
Because of its characteristic features, Dupuytren’s is not incredibly difficult to diagnose. In most cases, doctors do not require any labs or diagnostic testing to make a diagnosis of Dupuytren’s contracture.
The initial doctor’s visit begins with a discussion about the patient’s family history and past medical history, as those histories could contain risk factors for Dupuytren’s contracture.
Once the doctor obtains a thorough history, they will begin the physical exam. During the physical exam, they might:
A common test doctors have their patients perform is attempting to lay their hand flat, palm-down, on a table or surface. If the patient cannot flatten their hand completely due to contracted fingers, that is a good indication of Dupuytren’s.
There is still no cure for Dupuytren’s contracture, but there are several medical interventions available for the treatment of the condition. There are both surgical and non-surgical interventions to choose from. A doctor can help select the best treatment option for each individual case of Dupuytren’s contracture.
In the past, non-surgical treatment options were only for the earlier stages of Dupuytren’s contracture. However, doctors and scientists developed new non-surgical interventions in recent years, capable of treating Dupuytren’s even in late stages.
Radiation therapy can be useful in the earlier stages of Dupuytren’s contracture by softening nodules to improve comfort and preventing contractures from happening.
Doctors in the United States do not widely use radiation therapy for Dupuytren’s contracture due to the slight risk of radiotherapy causing cancer.
Steroid injections can be very helpful in slowing the progression of Dupuytren’s contracture. Doctors inject corticosteroids (anti-inflammatories) into cords to stop a contracture or into nodules to relieve discomfort.
Collagenase Enzyme Injections
Enzyme injections are a relatively new treatment, but in some cases, results are equal to or greater than that of surgery.
Enzyme injection treatment begins with the doctor injecting a collagenase enzyme into the cords on a patient’s palm. The enzyme works over the next one to three days to dissolve and weaken the deformed tissue.
The patient returns to the doctor, where under local anesthesia, the doctor carefully manipulates the fingers, breaking apart the contracted cords and straightening the fingers.
This treatment achieves comparable results to surgery without the pain and trauma that accompanies surgical operations.
Needle aponeurotomy is another new procedure showing promising results. The doctor also performs this procedure under local anesthesia. Once the patient is numb, the doctor penetrates the cords with a needle all the way through repeatedly.
The idea is that the deformed tissue does not need to be removed completely but rather lengthened or released. The doctor accomplishes this by weakening the bonds of the cords with a needle.
If Dupuytren’s contracture progresses past early stages, and the hand deformity affects daily life, doctors often recommend surgical intervention. Dupuytren’s contracture surgery works by either removing the deformed tissue or releasing the contraction of the cords.
The most common surgeries performed to correct Dupuytren’s contracture are fasciotomy and subtotal palmar fasciectomy.
Most patients experience positive surgical outcomes. However, the rate of reoccurrence is 20%, and some patients require additional surgeries in the future.
Doctors perform fasciotomies under local anesthesia. Once the patient is numb, the doctor uses a scalpel to make an incision into the palm and begins separating the contracted cords of tissue. During this procedure, the doctor does not remove the cords; dividing them is enough to achieve motion in the affected fingers.
The doctor does not apply stitches or staples when they’ve completed the surgery; they leave the wound open to heal over time. The patient must wear a splint while they’re healing from the surgery.
Subtotal Palmar Fasciectomy
Subtotal palmar fasciectomies are far more invasive surgeries. The doctor makes lots of incisions along the palm and fingers, sometimes in a zig-zag pattern. The goal of subtotal palmar fasciectomy is to remove as much of the deformed tissue as possible.
Sometimes doctors leave these incisions open after surgery. Other times they use a skin graft taken from another part of the patient’s body to lay over the palm and fingers to help close the wounds.
Not all doctors require patients to wear stents after undergoing subtotal palmar fasciectomy. However, extensive physical therapy is necessary to regain full function and range of motion in the hand.
Dupuytren’s contracture is not a life-threatening condition. Still, it does severely impact the lives of those who are affected by it.
Descriptions of Dupuytren’s contracture began appearing in medical literature in the 1600s, and there is still no cure for the condition. However, doctors and scientists have made considerable strides in advancing treatment options.
The frustrating thing about Dupuytren’s contracture is how recurrent of a condition it is. Someone may achieve perfect results from a surgery or treatment, only to have a recurrence a year or two later.
Many people require multiple surgeries and rounds of Dupuytren’s contracture treatment because the condition keeps coming back after being resolved.
While there’s no cure, there are treatments that can make living with Dupuytren’s contracture much more comfortable and reduce the likelihood of total hand deformity requiring a more invasive intervention.
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