Dupuytren's Contracture

A Common Problem of the Hand

More than 150 years ago a French physician first described the condition - Dupuytren's contracture - that bears his name. This common hand problem involves the formation of nodules and the shortening of fibers in the palm of the hand. It can eventually cause the fingers, most frequently on the ring and little fingers, to bend down toward the palm.

While the cause of Dupuytren's contracture remains a mystery, it is known to be a hereditary condition. A high percentage of people with Dupuytren's contracture are of Irish, Scotish or Scandinavian background.

Other factors that are sometimes associated with Dupuytren's contracture are systemic diseases, such as diabetes, rheumatoid arthritis, and alcoholism. Long-term use of anticonvulsive or seizure medications also may increase the risk of developing this hand condition.

Many therapies, including injections, diet, exercise, and medications have been tried over the years without success. Currently, the only effective treatment available for Dupuytren's is surgery.

This is very difficult, technically demanding surgery, and not everyone who has a nodule or band needs to have it removed. To be a candidate for this surgery, the patient must have an adequate degree of contraction and show a clear pattern of progression.

Dupuytren's contracture tends to be a slow and insidious type of ailment. It can take many years to develop. Often, the patient first notices a longitudinal band extending down the palm toward the fingers. Although it may appear as if a tendon in the palm is the problem, the tendons are normal.

Dupuytren's actually affects the dense, fibrous tissue between the skin and the tendons, called the palmar fascia, which functions as a stabilizer of the skin of the palm. The patient may also notice nodules or areas where the tissue has become very tight and hard. In the beginning, the band in the palm may feel like a tumor but there is no danger of this condition becoming cancerous.

While a nodule might be minimally tender under pressure, Dupuytren's contracture is generally painless. In fact, it rarely causes any symptoms or disability until the contracture of the fingers is quite severe. As the fibers that make up the palmar fascia are affected by Dupuytren's, they gradually tighten, becoming shorter. This can literally pull the fingers toward the palm. Although any of the fingers can be subject to Dupuytren's, the ring and little finger are more often affected.

Dupuytren's contracture is much more common in men, but it tends to be more severe in women who exhibit the condition. While it can occur in young people, it is usually seen in people in the fifth or sixth decades of life. Although the condition can be limited to one band, people often have the condition in both hands.

Since each patient's hand is likely to progress at a different pace, it is difficult to predict the course Dupuytren's will take for each individual. The prognosis is worse, however, if there is a strong family history of Dupuytren's, if the age of onset is early, and if there are associated findings. Associated findings include "knuckle pads", swelling over the nail side of the middle joint of the fingers, and plantar fibromatosis. The latter is the equivalent of Dupuytren's (palmar fibromatosis), which causes nodules on the soles of the feet.

For people with mild Dupuytren's contracture, it is simply recommended that they be checked at regular six to twelve month intervals. No treatment is necessary unless the band of the palm continues to shorten. Other than occasional tenderness, there is no disability until the contracture becomes severe. At that point, people experience difficulty in putting on gloves, getting change out of their pockets and shaking hands.

Unfortunately, if the contracture is allowed to progress to this severe stage, it may not be possible to restore normal hand function. The ideal time for surgery is after the pattern of progression has been established and before the contracture becomes severe.

For the best results, the surgeon must choose the optimal time to perform the surgery. The surgery is technically difficult, and the diseased fibers may be entwined with nerves and arteries, which must be preserved. In some cases, the diseased tissue extends to the skin, and, in order to prevent a quick recurrence, the skin must be removed and replaced with a graft.

There are risks associated with the surgery, including poor wound healing, injury to nerves, and swelling or stiffness of the fingers. Some patients do not do well because they have a genetic tendency to scar badly.

In order to increase the chances of a good outcome, the hand must he elevated for three weeks. After eight days, the patient begins to exercise the hand at regular intervals. Removal of the diseased tissue does not guarantee that there will be no recurrence. Today, only the diseased tissue is removed rather than the entire palmar fascia. Because the condition is not cured, previously unaffected areas of the hand can become involved following surgery.

It is actually better to do the surgery several times rather than waiting until the contracture is severe. When Dupuytren's is treated early on, the results of surgery are usually quite good.

Dupuytren's is the second most common hand surgery performed at the Lahey Clinic. This fact reflects the local population, which includes many people of Irish and Scotch background who are more susceptible to the condition than other groups.