Dupuytren contracture

What is Dupuytren contracture?

In the palm lies a thin sheet of fibrous tissue called the palmar fascia, which lies just under the skin. In Dupuytren disease, this fascia thickens and shortens, forming nodules and then dense cords that progressively pull the fingers down towards the palm. The condition is painless in itself, but as the cords tighten, the fingers can no longer be fully straightened, making it difficult to put the hand flat on a table, into a pocket, or to shake hands properly.

It is a slow disease, sometimes progressing over decades. Many people have firm nodules in the palm for years before any contracture develops, and some never progress at all. There is a strong genetic component, and it is most common in older men of Northern European descent. It can also affect the soles of the feet (Ledderhose disease) and the penis (Peyronie disease).

Treatment is only offered when the contracture starts to affect hand function. There is no good evidence that any treatment cures the underlying disease, all treatments aim to break or remove the affected cord, knowing that the disease may recur in time. Three main options are available: needle fasciotomy, collagenase injection, and surgical fasciectomy, each with different recovery profiles and recurrence rates.

Common causes

• Genetic predisposition, strongly familial
• Northern European ancestry
• Male sex (4-6 times more common)
• Increasing age, uncommon under 40
• Diabetes mellitus
• Smoking and heavy alcohol use
• Epilepsy and use of antiepileptic medication

Symptoms

Symptoms vary depending on the severity and duration of the condition. Common symptoms include:

• A firm lump or nodule in the palm, usually painless
• Thickened cords running from the palm into one or more fingers
• Inability to fully straighten the affected finger(s)
• Difficulty placing the hand flat on a table (positive tabletop test)
• Difficulty putting the hand in a pocket, wearing gloves, or shaking hands
• Most often affects the ring and little fingers; can affect any digit

How is it diagnosed?

Your hand surgeon will take a detailed history and examine the hand and wrist. The following investigations may be arranged to confirm the diagnosis:

• Clinical examination, characteristic palpable nodules and cords
• Tabletop test, can the hand be placed flat on a table?
• Measurement of contracture at the MCP and PIP joints (in degrees)
• Assessment of skin involvement (skin pits, adherent skin)
• Imaging is not usually required, the diagnosis is clinical

Treatment pathway

Treatment is tailored to the severity of the condition, your age, activity level, and overall health. Most conditions are treated in a stepwise fashion, starting with the least invasive options.

Recovery

After needle fasciotomy patients are back to most activities within a week. After open surgery the hand is splinted for two weeks, then hand therapy begins, this is a key part of the recovery and not optional. Night splints are often used for several months. Some stiffness, tenderness and scar sensitivity is normal in the first three months.

• Needle fasciotomy, return to normal use: 3-7 days
• Surgery, dressings and splinting: 2 weeks
• Hand therapy after surgery: 6-12 weeks
• Full recovery after fasciectomy: 3-6 months

What results can I expect?

Most patients achieve excellent correction with any of the available techniques. Recurrence is the major issue: roughly 50-60% by 5 years after needle fasciotomy, lower after open surgery. Patients with strong Dupuytren diathesis tend to recur faster. Younger patients with aggressive disease may need repeated treatment over the course of their lives.

In numbers