Dupuytren's contracture
Introduction
Dupuytren’s contracture is a condition that affects the hands and fingers. It causes one or more of the fingers, on one or both hands, to bend into the palm of the hand.
Dupuytren's contracture is caused by the growth of small lumps of tissue called nodules that develop in the connective tissue of the palm of the hand. The nodules are non-cancerous (benign) and the condition is not life-threatening for those who develop it.
Over time, the nodules can shorten (contract) this tissue, making it difficult to extend the finger fully, which eventually becomes permanently fixed in a bent position.
Although the symptoms of Dupuytren's contracture are often mild and painless, the condition can be progressive, getting steadily worse over time.
Read more about the symptoms of Dupuytren's contracture.
What causes Dupuytren's contracture?
In many cases, the exact cause of Dupuytren's contracture is unknown, but it seems to run in families. Other factors, such as diabetes, epilepsy, heavy smoking and heavy alcohol consumption, have also been linked to it.
Read more about the causes of Dupuytren's contracture.
Treating Dupuytren's contracture
Many cases of Dupuytren's contracture are mild and don't need treatment. Treatment may be needed if the condition is interfering with the normal functioning of your hand.
In severe cases of Dupuytren's contracture, surgery can help to release the contracted finger. The type of surgery used will depend on the severity of your contracture. The two most common surgical techniques are:
- fasciotomy, where the connective tissue is cut to relieve tension
- fasciectomy, where the connective tissue is completely removed
The chance of Dupuytren’s contracture reoccurring after surgery can be high (up to 50%). More extensive surgery is possible if the condition returns.
Collagenase clostridium histolyticum is a new non-surgical injection therapy for Dupuytren’s contracture. An enzyme (protein) is injected into the contracted tissue, which breaks down the contracture and helps straighten the finger.
Read more about treating Dupuytren's contracture.
Who is affected?
Dupuytren's contracture is a fairly common. It can affect both sexes, but tends to affect men more than women. The condition usually occurs during later life, although cases have been reported in children.
The symptoms of Dupuytren's contracture usually starts between the ages of 30 to 40, although women often develop symptoms much later. The condition seems to be more common in people from Europe, the US and Canada.
Ongoing research
Several treatments have been suggested for Dupuytren’s contracture, but there is currently not enough medical evidence to support their use.
For example, the National Institute for Health and Clinical Excellence (NICE) does not recommend the use of vitamin E cream or ultrasonic therapy. Trials into other possible treatments are currently underway.
Dupuytren’s contracture often runs in families and genetic research hopes to identify the genes responsible for the condition. This would allow the specific genes to be targeted, preventing the contractures from occurring.
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Symptoms
The main symptom of Dupuytren's contracture is small growths or lumps of tissue called nodules that develop on the palm of the hand.
Visit your GP if you:
- have any unusual lumps or dimples on your palm
- have any changes or thickening in the skin on your palm
- have any tenderness around your palm
- cannot straighten your fingers as much as you used to be able to
Nodules and cords
The nodules that develop in Dupuytren's contracture are caused by a thickening of the connective tissue, which is located just under your skin, above the tendons of your fingers.
Connective tissue is made up of fibres and it acts as a framework or support for other tissues and organs in the body.
In Dupuytren’s contracture, two fibrous structures grow in the connective tissue of your hand. They are:
- nodules: small lumps of tissue that contain fibroblasts (cells that make and release collagen)
- cords: bands of contracted (shortened) tissue that contain collagen
Collagen is a fibrous protein in your bones, skin and tendons. It also gives your connective tissue strength and flexibility.
When nodules begin to form, they produce too much collagen in your connective tissue. This causes the small, hard lumps that are typical in Dupuytren’s contracture.
Over time, usually several years, the nodules may form a cord in your hand. As it forms, the cord can contract the connective tissue in your hand, making it more difficult for you to extend your finger.
Progression
As Dupuytren's contracture progresses, your fingers may eventually be pulled into a permanently flexed (bent) position.
This can make it difficult to perform activities, such as swimming, playing a guitar or shaking someone's hand. The ring finger is usually affected first, followed by the little finger and then the middle finger.
Research has found that Dupuytren's contracture is not related to whether you are left- or right-handed. The condition affects a similar number of left and right hands.
In some cases, only one hand is affected, although it is common for both hands to be affected. In rare cases, Dupuytren's contracture also affects the toes and the soles of the feet.
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Causes
The exact cause of Dupuytren’s contracture is unknown, but research has shown there are several factors that make it more likely to develop.
Genetics is the most significant factor, with up to 70% of patients having a family history of the condition.
Genetics
Dupuytren’s contracture is an autosomal dominant disorder that can be passed on to you from your parents. Autosomal dominant means that you only need to inherit the gene that causes the condition from one of your parents, rather than both of them.
Read more about genetics and genetic inheritance.
Dupuytren’s contracture more frequently occurs in:
- males: one study found that the condition affects seven times more men than women
- people over 40 years of age: almost 80% of people with the condition are 40 to 70 years old
- people from Europe, North America and Canada: the condition is much less common in other parts of the world
Other contributing factors
There are a number of conditions that are slightly more common among people with Dupuytren’s contracture. They include:
- diabetes: a long-term health condition that is caused by too much glucose (sugar) in the blood
- epilepsy: a condition that affects the brain and causes repeated seizures (fits)
- cirrhosis of the liver: a condition where healthy liver tissue is destroyed and replaced by scar tissue
However, many people with Dupuytren’s contracture are not affected by these conditions.
There is also some evidence to suggest that heavy smoking and drinking increase a person’s risk of developing Dupuytren’s contracture. Your risk may also be increased if you have had a previous injury to your hand.
It has been suggested that Dupuytren’s contracture may be linked to manual work or using vibrating tools. However, there is no concrete evidence to support this.
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Diagnosis
In diagnosing Dupuytren’s contracture, your GP or specialist will examine the skin on the palm of your hand for the characteristic signs of the condition.
These are:
- lumps of tissue (nodules)
- dimples or pitted marks
- thickened skin
- flexed (bent) fingers
Dupuytren’s contracture affects everyone differently, so you will be asked about any specific symptoms that you have and any problems with carrying out daily activities. Some people are troubled by quite a minor deformity while others are able to cope with a more major one.
Deformed joints
If your finger is curling into your palm, the amount of deformity will be measured. This will be measured in degrees at each joint of your finger to see how bent it is. The fingers have three joints:
- the distal interphalangeal joint, which is at the top of your finger before your fingernail
- the proximal interphalangeal joint, which is the middle joint halfway down your finger
- the metacarpophalangeal joint, which is the knuckle where your finger joins your hand
Once the finger bends more than 30 degrees at a joint, most people start to have problems performing activities such as shaking hands, washing their face, opening doors, getting items out of their pockets and putting their hand flat on a table.
Surgery will usually be recommended if the condition is causing the metacarpophalangeal joint to bend more than 30 degrees or the proximal interphalangeal joint to bend more than 20 degrees.
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Treatment
In many cases of Dupuytren's contracture, the symptoms are mild and no treatment is needed. However, treatment may be required if the function of your hand is affected.
Surgery is an effective and widely used treatment for Dupuytren's contracture. The type of surgery that you have will depend on the severity of your contractures. The two most common procedures are:
- fasciectomy, where the connective tissue is completely removed
- fasciotomy, where the connective tissue is cut to relieve tension
Fasciectomy
A fasciectomy involves removing the thickened connective tissue. There are three variations of the procedure:
- partial fasciectomy, the most commonly used type of surgery for Dupuytren’s contracture, where only the affected connective tissue is removed
- segmental fascieotomy, where small segments of connective tissue are removed
- dermofasciectomy, where the affected connective tissue is removed along with the overlying skin (which may also be affected by the disease) and the wound is sealed with a skin graft (where healthy skin is removed from another part of the body and used to cover the area of skin loss in your hand)
A fasciectomy will usually be carried out under general anaesthetic. This means you will be unconscious throughout the procedure and unable to feel pain. In some cases, regional anaesthetic may be used. This is where local anaesthetic is injected into your hand to numb it, but you remain conscious.
During the procedure, an incision will be made in your hand and the affected connective tissue will be removed. If it is necessary to seal the wound using a skin graft, your surgeon will take a graft from an area of your body that is usually covered by clothing, such as your upper arm, the front side of your elbow or your groin.
A fasciectomy is a more extensive operation than a fasciotomy, so the risk of complications is slightly higher, at around 5% (see below). However, the results are longer lasting. For example, the rate of reoccurrence of Dupuytren’s contracture following dermofasciectomy may be as low as 8%.
Fasciotomy
There are two types of fasciotomy. They are:
- a needle fasciotomy
- an open fasciotomy
The two procedures are described below.
Needle fasciotomy
A needle fasciotomy is also known as a needle aponeurotomy or a percutaneous needle fasciotomy (percutaneous means "done through the skin").
It is usually performed as an outpatient procedure. This means you will not need to be admitted to hospital. You will be given a local anaesthetic that will numb your hand without making you lose consciousness.
During the procedure, a sharp blade or a very fine needle will be inserted into the fibrous bands in the palm of your hand or your fingers. The blade or needle will be used to divide the cord under your skin.
By dividing the thickened tissue, your surgeon will release the tightness in your hand that is forcing your finger to bend. The benefits of needle fasciotomy include:
- Your fingers are less deformed
- You recover more quickly compared with more extensive surgery.
- It is suitable for people who are unable to have more extensive surgery, such as the very frail or elderly.
- It has a low risk (around 1%) of complications.
The rate of reoccurrence for Dupuytren’s contracture is very high, with as many as 60% of people who have a needle fasciotomy experiencing Dupuytren’s contracture again within three to five years.
Open fasciotomy
An open fasciotomy is sometimes used to treat more severe cases of Dupuytren's contracture. The procedure is more effective in the long-term than a needle fasciotomy, but it is also a more extensive operation and therefore carries some additional risks (see below).
Like a needle fasciotomy, an open fasciotomy will be carried out as an outpatient procedure under local anaesthetic. The surgeon will make an incision in the skin of your hand so they can gain access to the connective tissue underneath. They will then cut the thickened connective tissue to divide it up, allowing you to straighten your fingers.
After the surgery has finished, the cut on your hand is sealed with stitches and a dressing is applied. The recovery time for an open fasciotomy is slightly longer than that of a needle fasciotomy because the wound will need time to heal.
Following the procedure, it is likely that you will need to make another appointment to have your stitches removed and you may be left with a small scar.
Surgery risks
If your surgery is complex and extensive, your risk of developing complications will be greater than if you have a more minor procedure.
For needle fasciotomy, the rate of complications is low, at around 1%. For fasciectomy, studies have found complication rates to be higher, from around 5%. Some possible complications are listed below.
- Splitting the skin with the needle during a needle fasciotomy.
- Damage to the nerves that supply sensation to your fingertips. The nerves can be repaired, but it is unlikely the fingers will recover their full sensation.
- Joint stiffness. This can be helped with hand therapy (find out about recovering from Dupytren’s contracture).
- Wound failure. The wound or graft failing to heal (more likely to occur if you smoke).
- Infection of the wound. This will usually be treated with antibiotics.
- Haematoma. A blood-filled swelling that forms as the wound heals, usually in the palm; it can be drained to reduce the swelling.
- Scarring
- Complex regional pain syndrome. A rare complication that causes the hand to become painful, stiff and swollen after surgery; it usually resolves itself within a few months, although sometimes it can be permanent.
- Finger loss (although this is very unlikely).
Discuss the risks of the surgical procedures that are used to treat Dupuyten’s contracture with your surgeon.
Non-surgical treatments
As well as surgery, there are also some non-surgical treatment options for Dupuytren's contracture, including radiation therapy and a new medicine called collagenase clostridium histolyticum. These are discussed below.
Radiation therapy
In 2010, the National Institute for Health and Clinical Excellence (NICE) issued guidance about the use of radiation therapy to treat Dupuytren’s contracture. Radiation therapy aims to prevent or delay the need for surgery.
During radiation therapy, over several days, controlled doses of high-energy radiation (usually X-rays) are aimed at the nodules and cords that have formed in your hand. If your symptoms are severe, you may need to return at a later date for further radiation treatment.
It is not known exactly how radiation therapy works, but it is thought that the radiation affects the development and growth rate of fibroblasts in your hand. Fibroblasts are cells that produce and release collagen (the protein that forms the main part of the body’s connective tissue).
In one of the studies reviewed by NICE, after one year, the symptoms of Dupuytren’s contracture had improved in over half of the hands that were treated. In another long-term study, two-thirds of people had some degree of symptom relief after 13 years.
Possible side effects of radiation therapy include:
- dry skin
- skin flaking off
- slight thinning of the skin
Radiation therapy is still being developed as a treatment for Duypuytren’s contracture and it may not be suitable for everyone. If you are offered radiation therapy, you should be aware of the uncertainty about its effectiveness and the possible long-term risk that radiation may cause cancerous tumours.
Collagenase clostridium histolyticum
Collagenase clostridium histolyticum is a fairly new medicine that has recently been approved for use in the UK by the European Medicines Agency (EMA). It can be injected into the cord that has formed in the palm of your hand.
The medicine contains special proteins that can break up the collagen fibres in the cord. This weakens the cord, allowing you to straighten your bent finger.
After having the injection, you return to your doctor 24 hours later, and they will straighten your bent finger and stretch it out for 10 to 20 seconds. This disrupts the cord and should help increase the range of movement in your bent finger.
Do not attempt to straighten your finger yourself within the first 24 hours, or squeeze or press the cord. Keeping your finger bent encourages the injected medicine to stay in the cord, which is where it needs to be.
If the first injection is not effective, you can have up to three injections in the same cord, with one month between each injection.
In one study that looked at collagenase clostridium histolyticum, nearly two thirds of people were able to almost completely straighten their finger after having the injections.
The most common side effects occur around the site of the injection and include swelling, bruising, bleeding and pain. These should improve within a week or two. Less common side effects include feeling sick or dizzy.
As with radiation therapy, collagenase clostridium histolyticum is still a relatively new treatment and the long-term effects are unknown. It may also not be widely available.
Where to have treatment
- Ask your GP for advice about whether the hospital you are being referred to has a specialist surgeon who is trained and experienced in performing hand surgery for Duypuytren’s contracture.
- Make sure that a good level of post-operative care is available. This means a dedicated hand surgery department, or an orthopaedic or plastic surgery department with a hand specialist. Where necessary, hand physiotherapy should also be available
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Afterwards
Recovering full or partial function of the hand following hand surgery for Dupuytren’s contracture can take a long time. Generally, the more extensive your surgery, the longer your recovery time.
It's important to discuss your recovery and any aftercare procedures that you may need with your specialist before having surgery.
Hand therapy
After surgery, you may need specialised hand therapy to help improve the function and range of movement of your hand. For example, you may need to have:
- physiotherapy: this could involve a number of techniques to help improve your range of movement, including massage, manipulation, exercise, electrotherapy and hydrotherapy
- occupational therapy: if you are struggling with everyday tasks and activities, either at work or at home, an occupational therapist will be able to provide you with practical support to make those tasks easier
How long you will need to have treatment or assistance for will depend on the type of surgery you have had. For example, if you have had a fasciectomy, you may need hand therapy for up to six months.
Splinting
Splinting usually involves bandaging your fingers to a plastic strip while they are in the straightest position that you find comfortable. Splinting may initially be recommended all day before being used only at night, and then not at all.
Splinting is not currently a standard procedure and some specialists prefer not to use splints. When splints are used, there is often wide variation in the length of time they are used for, the position of the fingers and how much force is used to keep the fingers straight.
Some specialists believe that splints can positively influence the way that scar tissue forms after surgery, so that the scar doesn't contract and cause the condition to return. Others believe that splints can cause unnecessary pain, joint stiffness and oedema (swelling), so prefer not to use them.
Several research studies have been carried out to try to determine whether or not using splints is effective in the recovery of Dupuytren’s contracture.
One study found that there was no difference between the range of hand movement experienced by a group of people who were routinely splinted after having a fasciectomy or dermofasciectomy and a group who received hand therapy and were only splinted if contractures occurred.
Reoccurrence
Dupuytren’s contracture can return to the same spot on the hand or it may reappear somewhere else. Reocurrence is more likely in certain circumstances, such as:
- You are a younger patient.
- Your contracture was severe.
- You have a strong family history of the condition.
The experience of the surgeon who carries out the procedure may also influence the chance of reocurrence.
After a needle fasciotomy, the rate of reocurrence can be as high as 60%. After a fasciectomy, this may decrease to 35%. For dermofasciectomy, the reocurrence rate can be as low as 8%.
Driving
After having hand surgery, you can start driving as soon as you feel confident enough to control the car safely. This will usually be after about three weeks, but it may be longer if you have had a skin graft.
Work and sport
When you will be able to return to work will depend on the nature of your job and the type of operation that you have had.
If you do heavy manual work, you may not be able to return to work for six weeks after having a skin graft. If you work in an office, you may be able to return to light duties a few days after having a fasciotomy. The same advice applies to sport.
Can Dupuytren's contracture be prevented?
As the exact cause of Dupuytren's contracture is unknown, the condition is difficult to prevent.
However, if you are at risk of developing the condition – for example, if you have had it in the past, or if you have a family history of it – reducing your alcohol intake (if you drink) and stopping smoking (if you smoke) may help to reduce your risk.
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