What is Dupuytren Contracture?
Dupuytren’s disease is largely a condition that affects the muscular tissues in the palms and fingers, leading to deformities in their movement. It most commonly affects the ring and pinky fingers. The disease starts off in the palm with the appearance of harmless bumps that follow certain lines of tension in the hand. These bumps then form cords which cause deformities in the hand’s tissues and bands.
Similar benign disorders to Dupuytren’s contracture include Peyronie’s disease, Ledderhose disease, and Garrod disease. It is most commonly seen in white people and usually affects both hands; however, if it only affects one hand, it’s likely to be the right. It is often the case that this disease runs in families, with men being more prone to it than women.
What Causes Dupuytren Contracture?
Dupuytren’s disease is a genetic condition that is often passed down through families, although it usually occurs due to a combination of various factors. It is linked with conditions like diabetes, seizure disorders, smoking, alcoholism, HIV, and vascular disease. However, it’s important to note that one’s occupation or activities aren’t considered risk factors for this disease.
Besides the hand, Dupuytren’s disease can also affect other parts of the body. For instance, it can affect the soles of the feet (known as Ledderhose disease) in 10% to 30% of cases, the tissue of the penis (known as Peyronie’s disease) in 2% to 8% of cases, and the tops of the knuckles (known as Garrod’s disease) in 40% to 50% of cases.
Risk Factors and Frequency for Dupuytren Contracture
This medical condition is most prevalent in people of Northern European or Scandinavian ancestry. According to a twin study conducted in Denmark in 2015, about 80% of its occurrence is related to hereditary factors. It’s less common in Southern European and South American populations, and rare in Africans and Asians. It affects men twice as much as women, and men also often experience more severe symptoms. The age at which the condition starts can also impact the severity of its progression. In Asian populations, it is more often seen in the palms rather than the fingers, making it less noticeable.
- This condition predominantly affects people of Northern European or Scandinavian lineage.
- Genetics play a large role in its occurrence, with about 80% heritability based on a Denmark twin study conducted in 2015.
- The condition is less common in people from Southern Europe and South America, and it’s rare in Africans and Asians.
- Men are affected twice as often as women and usually experience more severe symptoms.
- The earlier in life this condition starts, the more severe it can become.
- In Asians, it’s more commonly found in the palms, making it less conspicuous.
Signs and Symptoms of Dupuytren Contracture
Dupuytren’s disease is a health condition that first appears as a noticeable lump in the palm, typically near the distal palmar crease, which is the bottom line of your palm. These lumps then grow into cords. In the early stages, people might only notice these cords underneath their skin. As the disease progresses, these cords shorten and thicken, causing the fingers to bend towards the palm and become stuck in that position. This can lead to difficulties moving the hand and prominent cords underneath the skin of the palm extending into the affected fingers. The key signs of this disease are the appearance of lumps, cords, and stuck fingers. Pain is uncommon in patients with Dupuytren’s disease.
The fourth and fifth fingers are the most often affected. The condition can affect both hands, but it may not be equally severe on both sides. In general, the lumps do not cause pain when touched unless they are pressing on the ulnar nerve. However, they may become painful in the presence of tenosynovitis, an inflammation of the lining of the sheath that surrounds a tendon.
- Blanching (whitening) of the skin when the finger is straightened
- The cords do not cause pain above the vicinity of the lumps
- Pits and grooves may be visible
- The knuckle pads over the PIP joints (middle finger joint) may be sensitive
- If the bottom of the foot is affected, this indicates a more serious form of the disease, known as Ledderhose disease
- The tabletop test, i.e., the inability to flatten the hand on a table due to bent fingers, indicates a positive diagnosis
Testing for Dupuytren Contracture
Getting X-rays of the hand isn’t necessary. However, they can be useful to check for any bone issues like arthritis that could affect the hand’s mobility. Lab tests can help rule out conditions like diabetes that might contribute to the issue. An ultrasound may also be advised to see if the tissue on the palm of the hand is too thick and to look for any lumps or nodules.
Treatment Options for Dupuytren Contracture
Treatment decisions for illnesses often depend on how it is affecting a person’s quality of life. Some individuals with noticeable symptoms may choose to get treated.
There are a few different treatment options available including monitoring the disease and not intervening (also called conservative management), a minimally invasive procedure using a needle (needle aponeurotomy), injecting a substance that breaks down collagen (collagenase injection), or surgically removing the problematic tissue (fasciectomy).
Should the disease be stable and not affecting day to day life, monitoring may be all that is necessary. This could involve check-ups every six months. Physical and occupational therapy, as well as splinting and medications like corticosteroids, could help manage the condition. Certain treatments like tamoxifen, anti-tumor agents, and botulinum toxin have been tried, but there’s no concrete evidence on their effectiveness. Radiation therapy might work in the early stages but it comes with risks.
Needle aponeurotomy could be an option for minor contractures. This is a fairly simple procedure where the cords in the hand are broken up using a needle. However, this could potentially cause injury and almost 60% of patients might experience the condition again.
Collagenase injections, which are enzymes derived from a certain kind of bacteria, are another minimally invasive treatment. They’re injected into the cord in the hand and result in a significant reduction in contracture with a 35% chance of recurrence. But there are possible side effects like fluid buildup, skin tearing, severe pain, and ruptured tendons.
Lastly, one could undergo surgery to remove the diseased tissue. Depending on the severity of the disease, some or all of the fascia in the hand may be removed. The procedure is customized to the patient and has a recurrence rate from less than 10% to 30%, depending on the period post-surgery. Side effects might include skin death, blood accumulation, nerve and blood vessel damage, and infection.
Regardless of the treatment opted for, recurrence is a common issue, with a chance of 20-50% at 5 years.
What else can Dupuytren Contracture be?
Dupuytren’s disease is a condition that affects the hand, but it’s different from other similar hand conditions like tendonitis, cysts, nerve problems, and soft tissue tumors. For example, another hand condition, called stenosing tenosynovitis, might also cause a finger to be painful and difficult to extend, similar to Dupuytren’s disease. But this condition usually comes with a small lump or nodule near the joint where the finger meets the hand, which is a characteristic not present in Dupuytren’s disease. It’s important to accurately distinguish between these conditions since they have similar symptoms but require different treatments.
What to expect with Dupuytren Contracture
Dupuytren contracture can affect people differently based on how severe the disease is. This condition causes joints in the fingers to stiffen, which can make daily tasks, working, and certain lifestyle activities difficult. Some people might feel pain from the lumps caused by the disease. Additionally, it’s also possible for the disease to be linked to Peyronie disease, or it might involve the thickening of the skin over the knuckles. These associations commonly occur in severe cases of Dupuytren contracture.
Possible Complications When Diagnosed with Dupuytren Contracture
Surgery complications can arise including the death of skin around the surgical site, blood clots, damage to nerves, reduced blood supply to the fingers, infection, swelling, return of the problem, and after surgery issues. Reduced blood supply to the fingers can occur either from direct harm to the blood vessels, or due to vessels being injured in fingers that have been bent for a long time. It’s worth noting that the cord twisting around the finger can push neurovascular bundles out of place, making them more prone to injury.
Dupuytren flare reaction is a complication where the patient experiences pain along with widespread swelling, hypersensitivity, redness, and stiffness. If this occurs, treating it involves steroids, nerve blocking in the neck, therapy, and a surgical procedure that releases a tight loop of tissue in the finger. Let it be clear that the risk of a pain syndrome known as CRPS doesn’t increase if another procedure to relieve a nerve in the wrist (carpal tunnel release) is done alongside the surgery to take out the twisted cord (fasciectomy).
Common Complications:
- Death of skin near surgical site
- Blood clots
- Damage to nerves
- Reduced blood supply to the fingers
- Infection
- Swelling
- Return of the problem
- Problems after surgery
- Dupuytren flare reaction
Recovery from Dupuytren Contracture
After surgery, patients usually start hand therapy to keep their hand flexible and moving freely. They often use something called extension splints, along with other methods. It’s advised to continue with physical therapy for at least three months to prevent the hand from becoming stiff. It’s important to remember that the full benefits of the surgery won’t be immediate and usually become noticeable around six to eight weeks after the procedure.
Typical after-surgery care for the hand includes regular exercises to maintain movement, management of scar tissue and swelling, as well as the use of dynamic or static splints. These therapy activities should begin after the inflammation from the wound healing has reached its peak, which typically happens 3 to 5 days after surgery. It’s worth noting that effective after-surgery care can contribute to up to 50% of the overall success of the surgery, highlighting how crucial appropriate therapy can be.
