Definition and Overview

A Dupuytren's contracture is a hand deformity characterised by the painless thickening and tightening of tissue under the skin in the palm. The condition, which is also referred to as Dupuytren's disease, affects the fingers and causes them to bend into the palm.

Dupuytren's contracture is relatively uncommon in many countries, affecting about 5% of the U.S. population. However, it is prevalent in parts of northern Europe with up to 30% of Norwegian men over the age 60 suffering from the condition. It is also more common in people with epilepsy and diabetes and is sometimes associated with other disorders such as Peyronie disease, a condition in which scar tissue builds up inside the penis.

The disorder usually progresses very slowly and starts with a painless lump near the base of the fingers. Over the course of months or years, this lump can cause changes in the ring finger and then in the pinky. In rare cases, the middle finger is also affected. The condition can prevent patients from fully extending the affected fingers from a flexed position resulting in their inability to grasp things and perform routine tasks such as using utensils and writing, among others.

Causes of Condition

What causes Dupuytren's contracture remains unknown. However, scientists believe that the biological process involved in the division and differentiation of connective tissue cells called fibroblasts increases the risk of developing the condition. Any abnormalities that lead to the excessive production of myofibroblasts, a type of fibroblast that contains a type of protein (myofibrils) that allows muscle fibres to contract, is believed to put patients at an increased risk of developing this condition.

Other risk factors include:

  • Gender - Men are more likely to develop the condition than women and are more likely to suffer from severe contractures. The higher prevalence of the disorder in males is believed to be caused by the sensitivity of the fascia to androgens or male sex hormones such as testosterone.

  • Age - The majority of cases involve patients over the age of 50. However, the condition can also occur in children and young adults.

  • Diabetes - A Dupuytren’s contracture can be considered one of the complications of diabetes. Based on research, the frequency of the disorder is up to 10 times greater in diabetic patients than in the general population. However, the contracture is usually not severe and surgery is rarely indicated in such cases.

  • Tobacco and alcohol abuse

  • High cholesterol

  • Certain medications, such as anticonvulsants

  • Thyroid problems

  • Previous injury to the hand

Key Symptoms

Some of the earliest Dupuytren’s contracture symptoms are a minor painless lump and thickened skin on the palm. As it progresses, cords of tissue may form in the palm and cause the overlying skin to become dimpled or puckered. The affected fingers are pulled toward the palm when these cords begin to tighten. Patients usually do not experience any pain related to the condition unless the affected fingers are forcefully hyperextended.

In rare cases, joints or tendons in the hands and fingers become painful and inflamed. A small number of patients also complain of tension, pressure, itching, and burning sensation.

Who to See and Types of Treatments Available

Many cases of Dupuytren’s contracture are mild and do not require any form of treatment. Often, doctors advise watchful waiting if the patient is suffering from just thickened tissue or thickened tissue with a mild contracture because there are many instances where the condition improves without any medical intervention. However, if it worsens, patients are referred to specialists that focus on the diagnosis, treatment, and management of various hand problems.

The goal of Dupuytren’s contracture treatment is to stop the condition from worsening and improve hand function. Treatment options include non-surgical therapies, radiotherapy, and surgery.

In its early stages, the condition is treated by injecting a medicine designed to break the thickened tissues. Patients are advised to return to their doctor the next day to have their fingers stretched and straightened, a procedure that is often described as painful or uncomfortable. In some cases, radiation therapy is advised wherein patients are given several doses of radiation to the affected hand to slow the progression of the condition. For improved results, this is combined with Dupuytren's contracture exercises that patients can do at home. An example is laying the affected hand flat on the table and raising each finger up one at a time for 5-10 seconds.

Surgical treatment for Dupuytren’s contractures is advised if at least one of the knuckle joints is stuck at an angle of 30-40° or more and if there is a bend of 10-20° or more between one of the small joints of a finger. The goal of the procedure, which is also referred to as Dupuytren’s contracture release, is to remove the thickened tissue that is causing the condition.

Surgical treatment options include:

  • Closed fasciotomy - A minimally invasive procedure that involves inserting special needles through the skin to break up thickened tissue without making an incision. The treatment, which is usually performed on an outpatient basis and under local anaesthesia, is recommended instead of an open fasciotomy if the contracture is not in close proximity to important nerves and if the condition is in its early stages.

  • Open fasciotomy - Involves making an incision in the overlying skin to cut the thickened tissue. This is also an outpatient procedure but requires a longer recovery time when compared to closed fasciotomy. Open fasciotomy is preferred in many cases because doctors are able to fully assess the affected area and are able to take necessary precautions to minimise damage to nearby tendons, nerves, and blood vessels.

In cases where it is deemed that it is best to remove the thickened tissue (instead of just cutting it), hand surgeons perform an extensive hand operation, which provides the best chance of Dupuytren’s contracture cure. Patients usually require months of intensive physical therapy after in order to regain their hand function.

References:

  • Dupuytren's disease. American Society for Surgery of the Hand. http://www.assh.org/handcare/hand-arm-conditions/dupuytren-disease.

  • Calandruccio JH. Carpal tunnel syndrome, ulnar tunnel syndrome, and stenosing tenosynovitis. In: Canale ST, Beaty JH, eds. Campbell's Operative Orthopaedics. 12th ed. Philadelphia, PA: Elsevier Mosby; 2013:chap 75.

  • McGrouther DA, Jenkins A, Brown S, Gerber RA, Szczypa P, Cohen B. The efficacy and safety of collagenase clostridium histolyticum in the treatment of patients with moderate Dupuytren's contracture. Curr Med Res Opin. 2014;30:733-9. PMID: 24397625 www.ncbi.nlm.nih.gov/pubmed/24397625.

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