Dupuytren’s Contracture is a genetic disease that affects the hands and fingers. The condition causes the fascia, a layer of tissue underneath the palm of the hand, to thicken. This can cause the fingers of one or both hands to contract toward the palm, making it difficult for even daily activities. It’s one of the most common conditions that hand surgeons treat.
The earliest sign is a skin nodule in the palm that can be mistaken for a callus. It may enlarge and become painful, evoking concern for a tumor. However, the nodule caused by Dupuytren’s disease is always benign. A cancerous growth in the palm of the hand is exceedingly rare.
The disease is named after Guillaume Dupuytren, who is widely recognized as the greatest French surgeon of the 19th century. He described the disease and performed his first surgery to correct the condition in 1831, publishing his results in The Lancet medical journal.
The Cause of Dupuytren’s Disease
Although the precise cause of Dupuytren’s is unknown, those with a family history are at greater risk, although not everyone whose parent had the disease will develop it. There is no indication that it comes from performing a specific job or certain activities. However, a hand injury or even hand surgery may trigger the condition in individuals with a genetic predisposition. It affects more men than women.
Mild versus Aggressive Form of Dupuytren’s
Many cases of Dupuytren’s disease are mild, and the condition may progress very slowly. The small nodule will remain the same for years or even decades, not causing any problems, and many people will never need treatment. In general, Dupuytren’s is not painful unless aggravated by forceful activities that put pressure on the nodule.
The aggressive form of the disease can be debilitating, limiting the ability to perform everyday activities. In severe cases, bands of tissue underneath the skin develop into thick cords that contract the fingers, causing them to curl toward the palm. It most often affects the ring finger and the pinkie, but can affect all fingers, including the thumb. Over time, as the disease progresses, secondary contractures develop in the ligaments and tendons of the fingers, making the condition at least partly irreversible.
In its most severe form, known as “Dupuytren’s diathesis,” the disease affects patients at an early age, involves both hands, most digits, progresses more rapidly and is more likely to recur following treatment.
The physician usually makes the diagnosis based on the appearance of a patient’s hands and fingers and the range of movement. An MRI or other imaging studies are generally not needed.
Nonsurgical Treatment of Dupuytren’s
For patients with an early manifestation of the disease, such as a small lump in their palm but no noticeable symptoms, the best course of action is to be evaluated by a hand specialist, who can make an accurate diagnosis and record a baseline examination. Patients are generally advised to do nothing about the condition other than return to their physician every three to six months to see if the disease has progressed. Many will not develop symptoms for years, if at all.
However, if the disease progresses and starts interfering with hand function, different treatment options are available to slow the progression and improve motion in the affected fingers.
For some patients who are experiencing a painful nodule, a series of three cortisone injections may provide relief and slow the progression of a contracture. The effectiveness of a steroid injection varies among patients.
Another treatment entails the injection of an enzyme known as collagenase into the hand to break up the cord and enable the individual to regain movement in the affected fingers. This treatment is very effective, especially in the earlier stages of the disease. However, about 30 percent of patients may see a recurrence of Dupuytren’s within three years.
Surgical Treatment of Dupuytren’s
For those with progressive contractures, surgery is often the best course of action to restore hand function. Contracted fingers may make daily activities difficult or impossible, including reaching into a pocket, shaking hands, putting on gloves, or even washing one’s face. Using a keyboard is particularly troublesome, both because of the inability to straighten the involved digit and the impaired reach of the small finger. Pianists find the “extra octave” increasingly difficult as the span of their hand narrows progressively.
At HSS, we have strict criteria for recommending surgery. We do not recommend it for patients with early disease that is not interfering with their lives. We do advise patients to have their hand checked periodically, and we recommend a simple “table-top test” that can be done at home to help recognize progression. This is performed by simply placing one’s hand down flat on a surface – if one or more fingers can no longer lie flat on the table, it is time to visit the hand specialist.
Surgery is reserved for those with Dupuytren’s who are experiencing symptoms that impede hand function. The goal is to restore motion in their fingers so they can regain normal use of their hand.
The surgery entails removing excess tissue in the palm of the hand. It is an intricate outpatient procedure that should be performed by an experienced hand surgeon under magnification, as care must be taken to protect the nearby blood vessels, nerves and tendons.
When seeking a diagnosis or treatment, it’s better to see a doctor sooner rather than later. Once a contracture is severe, Dupuytren’s disease is more difficult to correct.
Dr. Scott Wolfe is acknowledged to be one of the most experienced, innovative and authoritative experts in orthopedic upper extremity care. He is recognized for his expertise in the wrist and complex nerve injuries, fracture care, and for his leadership in improving the surgical education, skill level, and techniques practiced by the most up-to-date hand surgeons.
