Dupuytren's contracture

Definition

Dupuytren's (du-pwe-TRANZ) contracture is a hand deformity that usually develops slowly, over decades. Dupuytren's contracture affects the connective tissue under the skin of your palm. 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 can't be straightened completely, which can complicate everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands.

Dupuytren's contracture most commonly affects the ring finger and pinky, and occurs most often in older men of Northern European descent. A number of treatments are available to slow the progression of Dupuytren's contracture and relieve symptoms.

Dupuytren's contracture

Dupuytren's contracture

Dupuytren's contracture is a painless deformity of the hand in which one or more fingers (in this case, the pinky) are bent toward the palm and can't be fully straightened. It results from a ...

Symptoms

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.

Early symptoms
Dupuytren's contracture usually begins as a thickening of the skin on the palm of your hand. As Dupuytren's contracture progresses, the skin on the palm of your hand may appear puckered or dimpled. A firm lump of tissue may form on your palm. This lump may be sensitive to the touch but usually isn't painful.

Later symptoms
In later stages of Dupuytren's contracture, cords of tissue form under the skin on your palm and may extend up to your fingers. As these cords tighten, your fingers may be pulled toward your palm, sometimes severely.

The ring finger and pinky are most commonly affected, though the middle finger also may be involved. Only rarely are the thumb and index finger affected. Dupuytren's contracture can occur in both hands, though one hand is usually affected more severely than the other.

Dupuytren's contracture

Dupuytren's contracture

Dupuytren's contracture is a painless deformity of the hand in which one or more fingers (in this case, the pinky) are bent toward the palm and can't be fully straightened. It results from a ...

Causes

Doctors don't know what causes Dupuytren's contracture. Some researchers have speculated that it may be associated with an autoimmune reaction, where a person's immune system attacks its own body tissues. Dupuytren's often occurs in concert with conditions that cause contractures in other parts of the body, such as the feet (Ledderhose disease) or penis (Peyronie's disease).

Risk factors

A number of factors are believed to increase your risk of the disease, including:

• Age. Dupuytren's contracture occurs most commonly after the age of 50.
• Sex. Men are more likely to develop Dupuytren's and to have more severe contractures than are women.
• Ancestry. People of Northern European descent are at higher risk of the disease.
• Family history. Dupuytren's contracture often runs in families.
• 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.
• Diabetes. People with diabetes are reported to have an increased risk of Dupuytren's contracture.

Complications

Dupuytren's contracture can make it difficult to perform certain functions using your hand. Since 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.

Preparing for your appointment

While you may initially bring your symptoms to the attention of your family doctor, he or she may refer you to an orthopedic surgeon.

What you can do
Before your appointment, you may want to write a list that answers the following questions:

• When did your symptoms begin?
• Have they been getting worse?
• Does anything make them better or worse?
• How does the contracture interfere with your day-to-day tasks?

What to expect from your doctor
During the physical exam, your doctor will visually inspect your hands closely, comparing them to each other and checking for any puckering on the skin of your palms. He or she will also press on different parts of your hands and fingers to check for toughened knots or bands of tissue.

Tests and diagnosis

A simple maneuver, called the tabletop test, can determine if you have a contracture in your hand. If you can lay your hand, palm down, flat on a tabletop, you don't have a contracture.

In most cases, though, doctors can diagnose Dupuytren's contracture simply by looking at and feeling your hands. Other diagnostic tests are rarely necessary.

Treatments and drugs

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.

Treatment involves removing or breaking apart the cords that are pulling your fingers in toward your palm. This can be done in several different ways. The choice of procedure depends on the severity of your symptoms and any other health problems you may have.

Needling
This technique uses a needle, inserted through your skin, to puncture and "break" the cord of tissue that's contracting a finger. Contractures often recur but the procedure can be repeated. Some doctors now use ultrasound to guide the needle. This might reduce the chance of accidental injury to nerves or tendons.

The main advantages of the needling technique are that there is no incision, it can be done on several fingers at the same time, and usually very little physical therapy is needed afterward. The main disadvantage is that it cannot be used in some locations in the finger, because it could damage a nerve.

Enzyme injections
The Food and Drug Administration has recently approved injections of an enzyme, collagenase clostridium histolyticum (Xiaflex) for the treatment of Dupuytren's contracture. The enzyme in this drug softens and weakens the taut cord in your palm. The day after the injection, your doctor will manipulate your hand in an attempt to break the cord and straighten your fingers.

In many ways, this is similar to the needling technique, except that the manipulation happens the next day, instead of during the injection procedure. The advantages and disadvantages of the enzyme injection are similar to needling, except that the enzyme injection may be more painful initially. Currently, enzyme injections can be used on only one joint at a time and treatments must be spaced at least a month apart.

Surgery
Another option is to surgically remove the tissue in your palm affected by the disease. This may be challenging because it's difficult to identify tissue in very early stages of the disease. Diseased tissue may also attach to the skin, making it difficult to remove and increasing the chances of recurrence.

The main advantage to surgery is that it results in a more complete joint release than that provided by the needle or enzyme methods. The main disadvantages are that physical therapy is usually needed after surgery, and the recovery time can be longer.

In some severe cases, surgeons remove all the tissue likely to be affected by Dupuytren's contracture, including the attached skin. In these cases a skin graft will be needed to cover the open wound. This surgery is the most invasive option and has the longest recovery time. People usually require months of intensive physical therapy afterward.

Lifestyle and home remedies

If you have mild Dupuytren's contracture, you may want to:

• Stretch your fingers. Gently bend your fingers backward from your palm. One way to do this is to place your fingers on the edge of a table, palm down, and then lift the palm upward gradually as you keep your fingers flat on the table.
• Use massage and heat. Before stretching, warm up your hands with a microwavable heat pack and then massage your palms with lanolin cream.
• Protect your hands. Avoid a tight grip on tools by building up the handles with pipe insulation or cushion tape. Use gloves with heavy padding during heavy grasping tasks.