Dupuytren’s Contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is thought to be genetic in nature. This condition is genetic. Genetic means that the condition runs in families. This condition is 7 times more common in men than women. It is more common in men of Scandanavian, Irish, or Eastern European ancestory. Interestingly, the spread of the disease seems to follow the same pattern as the spread of the Vikings culture in ancient times. The disorder may occur suddenly, but it is more common to progress slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.
The disorder begins in the connective tissue of the palmar fascia inside the palm of the hand. The normal tissue thickens into cords and contracts causing the finger to bend toward the palm. As the disorder progresses, the contraction can interfere with the ability to use the hand and finger—you can’t get your hand in your pocket or put on a glove. In the early stages, splints can be used to keep the finger straight but will not stop the progression. In advanced stages, surgery is needed to release or remove the contracted scar tissue (cords) so the finger can be functional. After surgery, a splint is usually needed for a short time; intense physical therapy is needed to prevent the contracture from returning; however, in about 10% of cases, the contracture returns in a finger that has had the cords removed.
The purpose of this information is to help you understand:
• The disorder Dupuytren’s Contracture including the normal anatomy of the hand
• the signs and symptoms of the disorder
• how the disorder progresses, and how you can measure its progression
• the treatments available to you now and later
• what you can expect from those treatments
• what you can expect long-term if you have this disorder
Anatomy and Function of the Hand
In order to understand what is happening to your fingers and hand, you need to understand the basics about the normal anatomy of your hand. This includes becoming familiar with the various parts that make up the hand. Also, you should understand the function of these parts, that is, how they make your hand work. Keep in mind that no one is going to give you a test, but the more you know, the more you will be able to talk with your doctors and healthcare team in words that will help them better understand your particular disorder. It will also help you understand what they are telling you about your particular problem.
Normal Hand
Tendon
Palmar Fascia
Bone
Muscle
Causes of Dupuytren’s Contracture
No one knows exactly what causes Dupuytren’s Contracture. The condition is rare in young people but becomes more and more common with age. When it appears at an early age, it usually progresses rapidly and is very severe.
Symptoms of Dupuytren’s Contracture
There are no symptoms of Dupuytren’s contracture other than the progressive deformity of the involved finger(s)—usually the ring finger. As the disease progresses, nodules can be felt along the cords. We are able to grasp objects with our hands by flexing our fingers. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. Normally, we are able to control when we bend our fingers and even how much. As the disorder develops, we lose this control. As the disorder progresses, the bending of the finger becomes more and more severe.
Without medical treatment, the contracture can become so severe that you cannot straighten your finger, and, eventually, may not be able to use your hand effectively. Because our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually seek medical advice for cosmetic reasons or the loss of use of their hand. At times, the nodules can be very painful. For this reason many patients are worried that something very serious is wrong with their hand.
Diagnosis of Dupuytren’s Contracture
Your doctor will ask you to tell him the history of your problem, such as how long have you had the problem, have you noticed it getting worse, and how has it kept you from doing your daily activities. He will ask if you have any pain. Then he will examine your hand and finger.
Your doctor can tell if you have a Dupuytren’s Contracture by feeling the palm of your hand and the fingers. No special tests are usually necessary. Abnormal fascia will thicken and can have nodules that feel like small cysts or nodules under the skin and along the fascia. These nodules usually form first in the palm of the hand. As the disorder progress, nodules will form along the finger. These nodules can be felt through the skin and you may have noticed them yourself. Depending on the stage of the disorder, your finger may have started to bend. The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten completely out. This will be considered 0 degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected fingers. How much of the ability to straighten out your fingers you have lost is measured in degrees.
Measurements taken at later follow-up visits will tell how well treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years and then suddenly nodules will begin to grow and their finger will begin to contract.
The “table-top” or flat-hand” test may also done. This test shows if you can flatten your fingers and palm against a flat surface. You can follow the progression of the disorder by doing the table top test yourself. Your doctor will tell you what to look for and when you should come back to see him.
Treatment of Dupuytren’s Contracture
There are two types of treatment for Dupuytren’s Contracture: surgical and non-surgical. How far advanced the contractures are will determine which is the best course of treatment for you.
Non-surgical:
In general as long as you can pass the flat-hand test you don’t need surgery. In the early stages of this disorder, frequent examination and follow-up is recommended. Treatment usually consists of a splint that keeps the finger straight. This splint is usually worn at night.
Surgical:
In the advanced stages, usually when the MCP joint reaches 30 degrees of flexion or there is any flexion in the PIP joint, surgery is recommended. Surgery can also be recommended based on the location of the affected joint. Sometimes skin grafts can relieve the contracture, but it is not uncommon for the contractures to return.
The goal of surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should be restored to normal. If the problem is not severe, it may be possible to free the simply by cutting the band under the skin. If the palmar fascia is more involved so that more than one finger is bent, your surgeon may remove the whole aponeurosis.
Anesthesia
Surgery is usually done under a general anesthetic, where you are completely asleep during surgery, or a local anesthetic, where the hand is numbed. With a local anesthetic you may be awake during the surgery, but you won‚t be able to see the surgery.
Once you are under anesthesia, your surgeon will make sure the skin of your palm is healthy and free of infection. The skin will be cleaned with a germ killing solution. An incision will me made in the skin. There are several types of incision that can be made, but most are made along the natural creases and lines in the hand. This will help make the scar less noticible once the hand is healed.
Once the palmar facsia is exposed, your surgeon will remove enough of it to allow you to straighten your finger. Special care is taken not to damage the nearby nerves and blood vessels. Once the fibrous tissue is removed, the skin is sewn together with fine stitches. A skin graft may be needed if the skin surface has contracted so much that the palm cannot be stretched out flat.
Because there are so many nerves in the hand, you may have some discomfort after surgery. You will be given pain medicine to control the discomfort you have. You hand will be bandaged with a splint. The splint will keep the hand open and the fingers out straight during healing.
Complications of Dupuytren’s Contracture
WHEN TO CALL YOUR SURGEON
Rehabilitation of Dupuytren’s Contracture
After your surgery you will be scheduled to see an Occupational Therapist or a Physical Therapist who specializes in rehabilitation of the hand. Physical therapy is needed to keep and increase the motion you have in your hand. Physical Therapy after surgery is very important in preventing the build up of scar tissue, preventing the return of contractures, and getting the most benefit from surgery. If you decide to have surgery, you must commit to doing the physical therapy needed to make your surgery as successful as possible.
Long Term Care of Your Hand With Dupuytren’s Contracture
Removal of the entire palmar fascia will usually give a very good result. The cure is often permanent, but depends a great deal on the success of doing the physical therapy as prescribed. There is little ill effect caused by removing the entire palmar fasica, although the fingers may “bend backwards” a little more than normal.
Dupuytren’s Contracture is not a life threatening problem. It is important to know that the nodules are almost always limited to the hand. The nodules are not cancerous and will not become cancer. If you receive regular examinations by your doctor and follow his advice, you should be able to limit the problems caused by this disorder. Surgery will probably eventually be required to release the contracture and to prevent disability in your hand. Surgery may cause some minor disadvantages, but these are much less disabling than the Dupuytren’s contracture.