Dupuytren's contracture

What is Dupuytren's contracture?

Dupuytren's contracture, also called Dupuytren's disease, happens when the tissue just under the skin of your palm becomes thicker and less flexible, forming firm lumps and cords. Over time, these cords can pull one or more fingers in towards your palm so they can't be fully straightened.

Symptoms of Dupuytren's contracture

It usually starts with small, firm lumps (nodules) and dimples or ridges on your palm, often in line with your ring finger. These can sometimes feel tender or uncomfortable to begin with, though this usually settles over time, and around a quarter of people notice some tingling, burning or itching in the affected hand.

In around one in three people, the nodules develop into tight cords that gradually pull the finger towards the palm. This tends to happen slowly, over months or years rather than weeks. The ring finger is most often affected, followed by the little, middle and index fingers, and occasionally the thumb. The web between your thumb and index finger can also become narrowed.

It's common to have it in both hands, and it isn't usually painful, though it can make it harder to use your hand for everyday tasks. Some people also develop related lumps elsewhere, such as small pads over the finger knuckles (Garrod's pads), lumps on the sole of the foot (Ledderhose disease), a stiff and painful shoulder (frozen shoulder), or, in men, an unusual curve to the penis (Peyronie's disease).

Causes of Dupuytren's contracture and who's at risk

The exact cause isn't known, but genetic factors seem to play a large part. Dupuytren's contracture often runs in families and is thought to be the most common inherited condition affecting connective tissue, though not everyone who inherits the relevant genes goes on to develop it, and cases without a family history tend to start later and be less severe. It's also more common in people of European, particularly Northern European, background.

You may be more likely to develop Dupuytren's contracture if you:

• are male, and over 40 or in midlife or older
• have a close relative with the condition
• smoke, or drink a lot of alcohol
• have diabetes, epilepsy, thyroid problems, high cholesterol or liver disease
• take anticonvulsant medicines for epilepsy
• have previously injured your hand, though many people have none of these risk factors.

It doesn't appear to be caused by manual work or using vibrating tools.

Does it always progress in the same way?

Not everyone with Dupuytren's disease goes on to develop a true contracture. Some people only ever have the early nodules in the palm, which can even fade without treatment in a small number of cases, while others progress over months or years to firm cords and one or more bent fingers.

Dupuytren's contracture is closely related to a small group of conditions that share the same tendency for connective tissue to thicken in other parts of the body, including Garrod's pads, Ledderhose disease, frozen shoulder and Peyronie's disease, described above. Having one of these doesn't mean you'll develop the others, but they're seen together more often than by chance.

How is Dupuytren's contracture diagnosed?

Your GP, physiotherapist or a hand specialist can usually diagnose Dupuytren's contracture just by examining your hand, feeling for the characteristic nodules or cords in your palm.

Scans and X-rays aren't usually needed, since the diagnosis is normally clear from the examination alone. Occasionally, an X-ray, ultrasound or MRI scan may be used by a specialist to rule out other causes of similar symptoms, such as arthritis, a ganglion cyst, calluses, or trigger finger.

How is Dupuytren's contracture treated?

There's no cure for Dupuytren's contracture, and treatment usually isn't needed in the early stages, while you can still put your hand flat on a table.

Non-surgical treatment

• Physiotherapy: A physiotherapist can guide you through stretching exercises and massage to help maintain movement in your fingers, though this won't reverse the condition.
• Shockwave therapy: This uses sound waves to try to ease the contracture, though the evidence for this is still developing.
• Steroid injections: Injections into a tender nodule can sometimes help with discomfort in the early stages, before a contracture has developed.
• Collagenase injections: An enzyme called collagenase can also be injected directly into a cord to help break it down, after which the finger can be gently straightened –; this is a recognised alternative to surgery, though it isn't yet widely available in every setting.

Surgical treatment

Surgery is usually considered once you can no longer put your hand flat on a table, or your fingers are affecting your daily activities. It's usually done under local or general anaesthetic, and you can normally go home the same day.

• A needle fasciotomy: This uses a needle inserted at several points along your palm to loosen and straighten the affected cord. It has the quickest recovery, usually up to two weeks, but the contracture is more likely to return than with open surgery, and there's a small risk of the skin splitting, along with pain and numbness.
• A fasciectomy: This involves a cut along the palm and finger so the surgeon can remove the thickened tissue and straighten the finger directly. Recovery usually takes 4 to 12 weeks, and it carries the lowest chance of the contracture coming back, though as with any surgery there's a risk of bleeding, numbness and infection.
• A dermofasciectomy: This is similar to a fasciectomy, but the overlying skin is also removed and replaced with a skin graft, usually taken from your upper arm. This means two procedures rather than one, and a longer recovery, but it's less likely than a standard fasciectomy to come back, and is often used for disease that has already returned once, or for more extensive disease in younger people.

Whichever treatment you have, your finger may not end up completely straight, and might not be as strong or flexible as before. You may be given a splint to wear at night, and hand therapy, including exercises, plays an important part in regaining movement afterwards.

When should I see a doctor?

See a GP if one or more of your fingers are bending and you can't put your hand down flat, or if you're having difficulty with daily activities because of it.