Dupuytren’s Contracture

Dupuytren’s contracture is a disorder of the palm of the hand and fingers. In a normal hand, fibrous tissue called fascia covers important nerves, blood vessels, muscles, and tendons, and helps stabilize the skin.

In Dupuytren’s disease, this fascia can become abnormal and thickened, forming cords. These cords are often mistaken for tendons because they can look and feel similar. Unlike a tendon, which moves when a muscle shortens and lengthens, cord tissue is static and does not move. There may be a single cord or several cords, and they may be separate or connected.

Most people with Dupuytren’s contracture will also have nodules or bumps in the hand. When first noticed, these nodules and cords may not change for a long time, or they may change slowly or quickly. Cords and nodules may become larger and thicker over time.

As the cords progress, they may begin to pull the fingers into a bent position toward the palm. This can make it impossible to fully open the fingers and may limit use of the hand.

Causes

The exact cause of Dupuytren’s contracture is unknown and complex. It is a hereditary disease, which means family history and ancestry can play a role. The problem is more common in men, people over age 40, and people of Northern European descent. Smoking, diabetes, alcohol use, lower body mass index, and aging are also associated with Dupuytren’s.

There is no evidence that hand injuries or specific jobs lead to a higher risk of developing Dupuytren’s contracture. There may be a mild relationship to trauma in someone who is already at risk. Occasionally after a distal radius wrist fracture, a patient may develop a single nodule in the palm. This nodule may or may not be tender, and it often does not progress to a bent finger joint.

Signs and Symptoms

Symptoms of Dupuytren’s contracture usually include lumps, nodules, and bands or cords on the palm side of the hands. The lumps are generally firm and stuck to the skin of the palm. The skin can seem thicker and puckered.

Think of the Dupuytren’s palm skin like a road. Some areas may be swollen and puffy like a speed bump. In other areas, the skin may be puckered and pulled down like a pothole. Thick cords may develop from the palm into one or more fingers and can cause bending of the fingers.

The ring finger and little finger are most commonly involved. One or both hands can be affected, and each hand can be affected in a different pattern and at different times.

The lumps can be uncomfortable in some people. However, Dupuytren’s contracture is not typically painful for most people. The disease may first be noticed because it becomes difficult to place the hand flat on a surface, open the hand fully, wash hands, wear gloves, hold large objects, place hands into pockets, or shake hands comfortably.

It is difficult to predict how the disease will progress. Some people have only small lumps or cords, while others develop severely bent fingers. The disease tends to be more severe when it occurs at an earlier age. Men may develop more severe symptoms compared with women. A strong family history, involvement in other areas of the body, plantar fibromatosis, Peyronie’s disease, or knuckle pads may also suggest a higher risk pattern.

Treatment

The presence of a lump in the palm does not mean treatment is required or that the disease will progress. Not all lumps in the palm are Dupuytren’s. A hand surgeon can evaluate the hand with a history and exam. Sometimes imaging such as x-ray, ultrasound, or MRI may be recommended.

Important factors include the size and feel of the mass, its location, whether pain is present, movement of the mass or surrounding skin, family history, and other medical conditions. In mild cases, especially when hand function is good, observation may be all that is needed. Splinting or stretching typically does not prevent worsening of the contracture, but it is generally safe to try.

For contractures that become bothersome, nonsurgical and surgical options may be discussed. These are typically considered when the contracture prevents the hand from lying flat on a table. The goal of treatment is to improve finger motion and hand function. Complete correction may not always happen, and even with treatment, the disease is not fully curable. Nodules and cords can return in the same or a different location.

Nonsurgical Treatment

One nonsurgical option is needle fasciotomy, also called needle aponeurotomy. This can often be done safely in a medical office or procedure room while the patient is awake. The hand and finger are injected with numbing medicine. Once the skin is numb, a needle is inserted below the skin to cut the cord in several locations. The physician then slowly stretches the hand and fingers to break the cord and help the hand straighten.

Small tears in the skin can occur and usually heal over a few weeks. Recovery is often only a few days, and the hand can be used as much as the patient is comfortable. The wounds must be protected to reduce infection risk. This procedure does not fully remove the cord from below the skin, and roughly one third of patients may see the cord return.

Another office procedure option is a two-step treatment using a collagenase injection. The medication is injected into the cord at the first visit to dissolve the cord. Swelling, bruising, and pain can occur after the injection, and the hand may be wrapped in a bulky dressing. The second visit is usually one or a few days later. The hand and fingers are numbed, and the physician slowly stretches and straightens the finger joints to break the cord.

As with needle fasciotomy, small skin tears can occur, and recovery may take a few days to a few weeks. The hand can often be used normally once swelling decreases and the numbing medication wears off. This procedure also does not fully remove the cord, and the cord can come back. Talk with your doctor about whether you are eligible for this injection.

Splinting and therapy may be used after treatment to help keep the hand and fingers straight. The main reason to undergo treatment is to improve the ability to straighten the finger, but working on the ability to make a fist during recovery is also important.

Surgical Treatment

Several surgical treatments are available for Dupuytren’s contracture. Painful nodules can be treated by opening the skin and carefully removing them. For cords, one procedure is called fasciotomy, in which tight cords are cut but not removed. This is less invasive because only a small cut or cuts are used, but because all the diseased tissue is not removed, the contracture may have a higher chance of returning.

Another type of surgery involves cutting the cords and removing as much of the nodule, cord, and diseased skin as possible. This is called fasciectomy. It often involves longer wounds and more extensive dissection.

A surgical plan is specific to each patient. Surgery may be performed with the patient asleep or awake using a variety of anesthesia techniques, and it is usually outpatient or same-day surgery. The skin is usually closed with stitches, although some portions of skin may be left open to help prevent recurrence of nodules. Blood on the dressings during the first few dressing changes can be normal because of the surface area involved.

After surgery, splinting and hand therapy, either physical therapy or occupational therapy, are often helpful to improve function of the affected finger. Surgical treatment may be more effective, but recovery is longer. Recovery time for fasciectomy surgery is usually about six weeks. Early exercises, splint use, and therapy can help reduce stiffness and improve the final result.

Source: American Society for Surgery of the Hand patient education material, adapted into a responsive format for web viewing.