Dupuytren's Disease

What Is Dupuytren’s Disease?

Dupuytren's disease, also called Dupuytren’s contracture, is an abnormal thickening and tightening of the normally loose and flexible tissue beneath the skin of the palm and fingers, called fascia. The pinkie and ring fingers are most often affected. Both hands are usually involved, although one may have worse symptoms than the other.

The fascia contains strands of fibers, like cords, that run from the palm upward into the fingers. In Dupuytren's disease, these cords tighten, or contract, causing the fingers to curl forward. In severe cases, it can lead to crippling hand deformities.

Dupuytren's Disease Symptoms

The signs of Dupuytren’s disease show up in phases:

• Nodules: These lumps under the skin in the palm of the hand are the first symptoms for many people. The lump may feel tender and sore at first, but this discomfort eventually goes away.
• Cords: The nodules cause these tough bands of tissue to form under the skin in the palm. These inflexible bands cause the fingers to bend, or "curl," forward toward the wrist.
• Contracture: As the curling gets worse, it becomes difficult, if not impossible, to straighten the fingers. People with Dupuytren's disease often have a hard time picking up large objects, or placing their hands into their pockets, something you might do every day to retrieve coins, cash, or your ID card. If you have this condition, you may also find it difficult to place your hand flat on the table, wear gloves, or shake hands, among other things.

Dupuytren's Disease Causes and Risk Factors

The cause of Dupuytren's disease is unknown, but certain biochemical factors that affect the palm's connective tissue may be involved. Injuries and overuse of the hand don’t cause it. Tendons aren’t affected.

However, certain things may make you more likely to develop Dupuytren's contracture. They include:

• Drinking a lot of alcohol, although most people with the disease do not have alcoholism
• Diabetes
• Seizures, such as those seen in people with epilepsy
• Smoking
• Having a relative with the condition
• Being of Northern European (English, Irish, Scottish, French, Dutch) or Scandinavian (Swedish, Norwegian, Finnish) descent
• Being a man over 40

Dupuytren's Disease Diagnosis

Your health care provider will ask you questions about your symptoms as well as your overall health, your health history, and your family’s medical history. Then they’ll examine your hands, wrists, and fingers.

Diagnosis of Dupuytren's disease typically involves feeling the palm areas to check for nodules and recording how many nodules are found. Your doctor will likely ask you to try to place your hands flat on a table.

You may have tests to:

• See how well you can grasp items with your hands.
• See how well you can pinch items with your fingers.
• Measure the feeling in your thumbs and fingers.
• Check your range of motion in your fingers, to see if you can straighten them all the way.

Medical staff may also take pictures of your hand to document how it looks.

These exams and tests will be repeated over time to determine if the condition is getting worse.

Dupuytren's Disease Treatment

There is no cure for Dupuytren's disease. However, the condition isn’t life- threatening, and it may not cause discomfort for many years, if ever. Some people with the condition never need treatment, just monitoring.

If it’s painful or interferes with a person's daily activities, there are treatment options, including medication and surgery.

Finger splints don’t help people with Dupuytren's disease and may even cause harm. Stretching the finger forcefully can actually speed up the inward curling of the finger.

Non-surgical treatment

• Steroid injection: If a nodule is extremely tender, your doctor may recommend a corticosteroid injection, also called a steroid shot. A corticosteroid is a powerful anti-inflammatory medicine, which reduces swelling and inflammation. It may help ease your pain and in some cases may prevent finger contractures from getting worse, but won't straighten your finger if you already have a contracture. You might need a series of shots to see long-term results.
• Enzyme injection: If your fingers are already bent, your doctor may give you a shot of collagenase (Xiaflex), a mixture of enzymes that help dissolve the thick and tight tissue. This weakens the tight bands and may allow your doctor to then stretch the tightened area. The most common side effects seen with Xiaflex are swelling, bleeding, bruising, or pain at the injection site. Rarely, tendon or ligament damage may occur that requires surgery to fix. Your doctor can help you decide if enzyme injections or surgery is right for you.

Surgical treatment

If the condition continues to get worse despite medications and your hand function is severely limited, your doctor may recommend surgery. The two most common types are:

• Fasciotomy: This procedure divides the thick cord of ligament tissue so the affected finger can move more freely. Your doctor numbs the area and makes a small cut in your palm near the affected finger. You’ll need to wear a splint while the area heals.
• Subtotal palmar fasciectomy: With this procedure, your doctor removes as much of the cord and tissue as they can so your finger can straighten out. They’ll probably make a “zig-zag” cut in your hand to reach the affected area. This is a more complicated type of surgery than a fasciotomy, so there’s more involved in recovery, including careful care of the area and possibly physical therapy and a skin graft (when healthy skin is taken from another part of your body to seal the wound).

You’ll have some hand swelling and discomfort after the procedure. Raising your hand above your heart level and flexing your fingers can help relieve swelling, stiffness, and pain and speed up your recovery. Recovery can take several months.

Most people can move their fingers better after traditional Dupuytren's contracture surgery. However, the condition returns in about one in five people who have had this surgery.

Surgical Risks

All surgery comes with risks. Complications of surgery are rare but may include:

• Infection
• Injury to the nerves and blood vessels in the hand
• Permanent stiffness of the fingers

A procedure called aponeurotomy is an alternative to traditional surgery for Dupuytren's contracture. Instead of an open cut, it uses the sharp end of a needle to cut the thick bands under the skin, which may help you recover faster. However, it doesn’t work as well for people with more serious cases. Overall, there is less risk of complications, but there is a risk of nerve, blood vessel, or tendon damage. Needle aponeurotomy is even more effective when used in combination with corticosteroid injections. A specialized hand surgeon must perform this procedure. Ask your doctor what type of surgery is best for you.

Your doctor may recommend physical therapy after surgery.

When to See a Doctor

Dupuytren's contracture isn’t a dangerous condition, but it can be disabling if it becomes severe.

Call your doctor for an appointment if:

• You have one or more lumps in your palm, whether or not it is painful.
• You have difficulty straightening your fingers.
• You have difficulty grasping objects.
• You cannot place your hand flat on a table or place your hand in your pocket.

Dupytren’s Disease Complications

Because Dupuytren’s disease doesn’t usually affect your thumb or index finger, it may not bother you much early on. But it’s still important to see your doctor if you think you may have symptoms. It can get worse over time and eventually keep you from being able to open your hand, hold large objects, or fit your hand into small spaces.

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