Dupuytren’s contracture is a hand condition that slowly progresses over time, usually months or years. It affects the layer of tissue under the skin of the palm. It is a condition that causes one or more fingers to bend toward the palm, making it difficult to straighten the fingers. This article explores the various aspects of Dupuytren contracture, from its symptoms and causes to evidence-based treatments. Whether you’re personally affected by this condition or know someone who is, understanding it is essential. This comprehensive guide will cover everything you need to know, making it a must-read.
Article Outline:
- What is Dupuytren’s Contracture?
- Signs and Symptoms: How Do I Know If I Have Dupuytren Contracture?
- Causes of Dupuytren Contracture: What Leads to This Condition?
- Risk Factors: Who is Most Likely to Develop Dupuytren Contracture?
- Examining the Role of Genetics in Dupuytren’s Contracture
- Dupuytren Contracture Diagnosis: How is it Determined?
- Nonsurgical Treatment Options: What Are They?
- What Is Collagenase Treatment for Dupuytren Disease, and Is It Any Good?
- Surgical Treatment: When is Surgery Necessary?
- Recovery and Rehabilitation After Treatment
- Preventing Dupuytren Contracture: Is It Possible?
What is Dupuytren’s Contracture?
Dupuytren contracture is a condition where the fascia, the fibrous layer of tissue that lies beneath the skin in the palm and fingers, becomes thickened and tight. This condition leads to the formation of nodules and cords that can cause the fingers, typically the ring and little fingers, to curl toward the palm, restricting movement and impacting hand function. The nodules may get worse and a contracture develops. As the Dupuytren contracture progresses, the nodules may thicken with the bands of tissue that the disease causes and may need surgery eventually.
Dupuytren’s does not only affect the hands, similar symptoms can occur in the foot (ledderhose disease) in the penis (Peyronie disease).
Signs and Symptoms: How Do I Know If I Have Dupuytren’s Contracture?
The first primary symptom of Dupuytren contracture is usually a noticeable lump in the palm, which may develop into a thick cord that pulls one or more fingers toward your palm. Initially, the contracture may not cause pain, but as the fingers begin to bend, discomfort and a reduction in hand mobility can occur. Recognising these signs early can be crucial for effective treatment. One-quarter of people with Dupuytren have progressive symptoms.
Causes of Dupuytren Contracture: What Leads to This Condition?
While the exact cause of Dupuytren’s contracture is unknown, it involves a change in the tissue under the skin of the palm of the hand. Over time, this tissue can thicken and shorten, pulling the affected fingers inward. Research has shown it could be linked to an autoimmune reaction, where the body mistakenly attacks its own tissues (1).
Risk Factors: Who is Most Likely to Develop Dupuytren Contracture?
Risk factors for patients with Dupuytren’s include age (most common in people over 50), ancestry (predominantly affects individuals of Northern European descent), sex (more prevalent in males), and family history. Those with a familial predisposition are particularly susceptible.
Examining the Role of Genetics in Dupuytren’s Contracture
Genetics play a significant role in people with Dupuytren’s contracture, most often running in families. Research shows that specific genes may influence the likelihood of developing the condition, highlighting the hereditary nature of the condition.
Diagnosis: How is it Determined?
Diagnosis usually involves a physical examination where a health professional will look for palpable cords and nodules in the palm, along with the degree of finger flexion. The contractures typically affect the little and ring fingers. Imaging tests are rarely necessary unless complications arise or to differentiate from other conditions.
Nonsurgical Treatment Options Available: What Are They?
A recent Systematic Review (2) showed that for early stages or mild forms of Dupuytren’s contracture usually several nonsurgical treatments may be recommended. These include Extracorporeal Shockwave Therapy (ESWT), Steroid injections, Splinting, Massage and Stretching, Ultrasound Therapy and Temperature Controlled High Energy Laser (THEAL). For people in the early stages of the disease, these were used to manage symptoms slow progression and stave off the time when patients need contracture surgery.
- Shockwave Therapy for Dupuytren’s Contracture
The systematic review looked at 8 different studies on ESWT, two were case reports, three case series and 3 randomised controlled trials, with varying quality scores. Seven looked purely at shockwave and 1 combined it with traditional physiotherapy.
Five of the studies looked at Visual Analogue Scale scores for pain and four of them found a decrease in pain from initial to final assessments. The two studies that looked at patient satisfaction showed improvements in the intervention groups. Strength was not improved with any of the studies except the one that combined shockwave with traditional physiotherapy.
Most of the studies also reported improvements in patient-reported outcome measures (PROM’s) but these improvements were not sustained in the long term. Four of the studies reported improvements in ROM too. So Shockwave Therapy may be a good choice of treatment for patients looking to stave off surgery for Dupuytren’s contracture.
- Cortico-Steroid Injections
Although these studies showed temporary reductions of the nodule size (shrinking by an average of 56%), some grew back necessitating further injections. A word of caution, however, there were a couple of instances of spontaneous tendon ruptures, although these were reported as not directly linked to the study periods. There have been good quality studies that have shown links to steroid use and tendon ruptures (Achilles, bicep – both proximally and distally, finger tendons) and significantly increased risk in upper limb tendon ruptures (3).
- Splinting
Three studies looked at splinting and all reported improvements or stabilisation in hands and fingers range of motion. Particularly at the metacarpophalangeal (MCPJ) and proximal interphalangeal joints (PIPJ). The splint type used and the length of time-worn were varied. Long-term outcomes were varied with some patients showing regression after discontinuing the splint.
- Massage and Stretching
Interestingly, when cross-frictional massage was combined with stretching, it showed significant improvements in ROM compared to just stretching alone. However, pain levels remained unchanged. Ultrasound and photographic comparisons noted reductions in nodule size and visibility of contractive bands in the intervention groups.
- Ultrasound Therapy
The studies included in the systematic review were over 40 years old. They all combined ultrasound with other various physiotherapy modalities making it impossible to draw any reliable conclusions about the validity of ultrasound as a treatment in isolation. It would be difficult to recommend that ultrasound be used to treat the condition.
- Temperature-Controlled High Energy Laser (THEAL)
THEAL was shown to significantly decrease pain levels shortly after treatment and maintained lower scores over time. Significant improvements were also seen in PROM’s. There were however no changes in the ROM in the hands. So while THEAL may reduce pain and improve quality of life, it does not affect the physical contraction of the tissue involved in Dupuytren’s disease.
What Is Collagenase Treatment for Dupuytren Disease, and Is It Any Good?
In this treatment approach, enzymes called collagenase are injected into the cords. The idea is that the enzymes break down the collagen in the cords so the Dupuytren contracture may be straightened out. This was NICE recommended in 2015 in the UK, but that guidance has now been withdrawn as the clostridium histolticum is no longer available in the UK. A more recent set of guidelines written by a Dutch Dupuytren study group also concluded that currently collagenase injections to treat Dupuytren disease should be restricted to clinical trials.
When is Surgery Necessary?
Surgery may be considered when a sufferer’s symptoms may get worse enough to significantly interfere with hand function. As the contracture of the fingers progresses, the fingers are pulled more to the palm of your hand, and it gets increasingly impossible to get the hand flat. Procedures like fasciectomy, where the diseased fascia is removed, or fasciotomy, which involves cutting through the Dupuytren’s cord to release tension, are common surgical options.
If you need to see a hand surgeon our specialist hand therapists work closely with specialist hand orthopaedic surgeons and can recommend the best person to see for your situation.
Recovery and Rehabilitation After Treatment
Recovery varies based on the treatment method. Surgical treatments may require weeks to months of rehabilitation to regain full hand use. Hand therapy, including exercises and sometimes splinting, is crucial for a successful recovery.
Preventing Dupuytren Contracture: Is It Possible?
There is no known way to prevent Dupuytren contracture, but early intervention can help manage the condition and maintain hand function. Regular hand exercises and monitoring for signs of the disease may be beneficial in at-risk individuals. At the first signs of disease, it is useful to get treatment early to try and slow the disease. As the affected hand develops more severe symptoms, then surgery to remove the fibrous tissue called fascia using a technique called a fasciectomy, is currently the gold standard of care (3 and 4).
Key Takeaways:
- Dupuytren contracture involves the thickening of palm tissue, causing fingers to bend inward.
- Symptoms typically start with lumps in the palm and can progress to limited finger movement.
- Genetics and certain demographics increase the risk of developing the condition.
- Treatment can be nonsurgical or surgical, depending on the severity.
- There is no prevention for Dupuytren’s, but early treatment with a specialist hand therapist can manage symptoms and maintain functionality.
This article aims to provide comprehensive insight to help those affected by Dupuytren or at risk of this condition understand their options and the nature of the disease. If you or someone you know has been having problems with their hand that they suspect is Dupuytren’s then get in touch and let one of our Advanced Hand Specialist Therapists assess it for you.
Citations:
1 – Mayerl, C. et al. (2016) ‘Characterisation of the inflammatory response in Dupuytren’s disease’, Journal of Plastic Surgery and Hand Surgery, 50(3), pp. 171–179. doi: 10.3109/2000656X.2016.1140054.
2 – Fernando JJ, Fowler C, Graham T, Terry K, Grocott P, Sandford F. Pre-operative hand therapy management of Dupuytren’s disease: A systematic review. Hand Therapy. 2024;0(0). doi:10.1177/17589983241227162
4 – Kemeler, M et al. Dutch Multidisciplinary Guide on Dupuytren Disease. Journal of Hand Surgery. 2023:5(2):P178-183. DOI:https://doi.org/10.1016/j.jhsg.2022.11.008
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