Dupuytren’s Contracture
Dupuytren’s Contracture | Denver, Colorado
Dupuytren’s disease, which can sometimes progress to Dupuytren’s contracture, is a condition I treat routinely in my hand surgery practice in the Denver metropolitan area.
Dupuytren’s is an inherited condition that has no cure. It causes thickening of the layer of tissue just beneath the palm skin, known as the palmar fascia. In many cases, the disease will cause nodules and longitudinal areas of thickening called cords. In some patients, these cords will contract, leading to a Dupuytren’s contracture. Depending on how severe the contracture gets, these contractures can have a significant impact on hand function.
Dupuytren’s Diagnosis & Treatment
Figure 1 - A Dupuytren’s contracture of the ring finger
Diagnosing Dupuytren’s is typically straightforward after a detailed discussion and examination of the patient. Dupuytren’s disease will present with nodular thickenings in the palm and Dupuytren’s contracture will demonstrate contractures along lines of thickened cords in the palm (see Figure 1). Additional imaging or testing is not needed beyond a physical examination and discussion with your doctor.
A difficult reality of this condition is that there is no treatment for the disease itself. The only thing we can treat is the contractures that may develop. These contractures are rigid and do not respond to stretching, therapy, or any other kind of at-home treatment.
The most important thing to do at home is monitor the presence of nodules or cords in the hand. If they progress to an early contracture, see a hand surgeon right away. Early treatment of contractures is far more successful than waiting until they are severe.
Dupuytren’s Injections and Surgery
If you have developed a Dupuytren’s contracture, seeking treatment can greatly improve the function of your hand.
The first option is what is known as a collagenase injection. The current brand name for this is Xiaflex - I have no affiliation, but you may have seen their advertisements. This is great for mild to moderate contractures and involves injecting an enzyme directly into the Dupuytren’s cord, and then forcibly rupturing the cord several days later. This is all done in the office under local anesthesia (a numbing injection).
Some patients choose to skip the injection for surgery, or their contracture is too severe for the injection. The most common surgery for Dupuytren’s is known as a fasciectomy. In this procedure, the diseased tissue is cut out from the palm and finger, allowing the finger to straighten again.
Additional Information
If you’d like more information on Dupuytren’s, please continue reading through the frequently asked questions below. You can also access my ‘deep dive’ section to the right of the FAQs where I have links to the longer-form articles I have written about various topics related to Dupuytren’s and its treatment.
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The Basics
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Dupuytren's Disease (DD) is a soft tissue disorder affecting the hand, with Dupuytren's Contracture (DC) being its more advanced subtype. Approximately 20% of patients with DD will progress to a DC.
In basic terms, DD involves fibrotic changes to the palmar fascia, a thick layer of soft tissue that lies beneath the palm skin. In DC, these thickenings contract. These contractures can limit hand function and may require intervention from a hand surgeon.
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Despite much ongoing research, the root cause of DD remains unclear, and there is currently no cure. Dupuytren’s is strongly genetic, often passed through generations. Even so, a single gene or consistent pattern has not been identified.
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Dupuytren’s disease most commonly affects people aged 50-70 and has been reported in up to 21% of Caucasian males in Western countries by the age of 65.
It is more prevalent in men, with female patients typically developing symptoms 10-15 years later than their male counterparts.
Traditionally, it has been most commonly found in families of Northern European descent. This is what has led to its nickname over the years as “Viking Disease.” However, it has been reported to varying degrees in all races and ethnicities.
Of all people who develop Dupuytren’s Disease, about 20% will progress to develop a contracture of the hand.
Dupuytren’s Symptoms & Diagnosis
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Dupuytren’s Disease can manifest in many ways.
Early DD symptoms include skin tightness and the appearance of nodules or small masses, often over a palm crease. These can evolve into cords or linear masses. If these cords contract, it will result in an inability to straighten the fingers.
However, DD can also manifest outside the palm. Patients may notice thickening or nodules on the backs of their knuckles. Similar findings can also be found outside the hand, including nodules on the soles of the foot. Male patients may experience fascial changes of the penis, including nodules or even contractures (ie, Peyronie’s Disease).
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Dupuytren’s is a ‘clinical diagnosis,’ which means no fancy tests, imaging, or labs are needed. An experienced doctor can determine the diagnosis following a careful discussion and examination.
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Additional imaging or testing is unnecessary for Dupuytren’s. A discussion and examination with your doctor is typically sufficient.
If you have evidence of Dupuytren’s outside of the hand, you may need to visit with an additional specialist such as a foot & ankle surgeon, or a urologist.
Dupuytren’s Treatment
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Unfortunately, there is not much to do at home as far as treatment goes. This is a genetic condition that cannot be cured. Contractures have been historically resistant to any sort of stretching, exercises, or external forces.
The most important thing to do at home is monitor the disease. If you have developed nodules in the palm, it is critical to detect if they begin to progress to a contracture.
This can be done with the tabletop test. Every 3 months, place your palm and fingers flat on a table. As long as you can get your hand flat, you are in good shape. If ever your fingers cannot all lay flat on the table, see a hand surgeon right away. Early treatment is far easier and more effective than waiting too long.
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As mentioned above, Dupuytren’s contractures are very stout and are resistant to any sort of stretching or manipulation. Physical therapy is not a routine part of Dupuytren’s care.
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When activity modification and bracing strategies do not overcome your symptoms, you may wish to consider a steroid injection.
In this procedure, a small amount of steroid is placed into the first dorsal compartment. This will coat your tendon in anti-inflammatory steroid medicine. This will decrease the irritation and inflammation over 2-3 weeks after injection, easing the pain of De Quervain’s.
While these can offer tremendous relief, they must be approached with some caution. This particular injection can cause cosmetic side effects on occasion. This includes skin bleaching in some and fat atrophy in others. Fat atrophy refers to a process in which the normal fat under the skin shrinks, causing a divot-like appearance in the wrist. In some cases, these cosmetic changes can be permanent, so it is something to consider before receiving an injection for De Quervain’s.
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CCH injection treatment is very effective. While the specific anatomy of your cord and contracture will determine the likelihood and extent of success, the vast majority of fingers will be markedly straighter than prior to injection.
Though the data is still new, it does appear that recurrence after injection is slightly earlier than recurrence after surgery. Remember, there is no cure for this disease so many contractures do come back over time. The current average recurrence after injection is 3-5 years, while a surgical fasciectomy lasts closer to 6-8 years.
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There are several risks to this injection treatment, just like any other treatment in medicine. Fortunately most are minor or temporary.
The majority of patients get swelling and bruising of the hand, and even as far as the armpit, after injection. This resolves after a few days.
With the manipulation, some patients experience a tear in their skin. Most do not. This almost never needs stitches and will heal in a week or two.
The most severe risks are fortunately rare. One is an allergic response. While rare, this can be serious. The other is tendon rupture. The reported rate of rupturing a tendon with this injection is 1 in 10,000. Unfortunately, this would require a sizeable surgery to repair if it occurs.
Dupuytren’s Surgery
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The most common surgery for Dupuytren’s is a surgical fasciectomy. In this procedure, a large incision is made along the length of your abnormal tissue and the tissue is meticulously removed. This palmar fascia tissue is often wrapped around nerves and blood vessels and takes great care to excise.
Once the tissue is excised, most fingers relax back into a straight position. If the contracture is particularly severe or longstanding, you may require additional procedures to restore finger function.
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Due to the length of time it takes to meticulously remove the palmar fascia tissue, a light anesthesia is required for this procedure.
In this setting, your arm will be numbed by an anesthesiologist and you will then be given a ‘twilight’ sedation (similar to a wisdom tooth extraction or colonoscopy procedure). With this sedation you will feel asleep but will be breathing on your own without the need for a breathing tube.
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The initial phase of healing after Dupuytren’s is focused on healing the large skin wounds and maintaining finger extension. Sutures are removed after about 2 weeks. You will work with a certified hand therapist who will make you custom hand extension splints to wear while you heal. Therapy and splinting continue for 3 months after surgery in most cases.
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All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding tendons/nerves/vessels, anesthesia risks, or failure of the procedure.
The most common risk of Dupuytren’s surgery is what we call a ‘neuropraxia.’ This is when a nerve ‘goes to sleep’ after surgery.
There are sensory nerve branches to the fingers that are often tangled in the palmar fascia tissue excised during surgery. In surgery, I will identify and carefully protect those nerves. Sometimes, even just this light touch of protecting the nerve or removing the tissue from around the nerve will cause it to ‘panic’ and shut down for a period of time.
If this happens to you, you will notice an area of numbness or tingling over the finger. The nerve will typically ‘wake up’ over a period of a few weeks to a few months after surgery.
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Surgical fasciectomy for Dupuytren’s contracture is very effective. While the specific anatomy of your cord and contracture will determine the likelihood and extent of success, the vast majority of fingers will achieve near-complete extension.
Remember, there is no cure for this disease so many contractures do come back over time. The current average recurrence after CCH injection is 3-5 years, while a surgical fasciectomy lasts closer to 6-8 years. Many patients get permanent resolution of their contracture. We still don’t have a great way of predicting in which patients contractures will recur and which will not.