Dupuytren's contracture

Dupuytren’s contracture is a condition that affects the hands and fingers.

Contents

Introduction

Dupuytren’s contracture is a condition that affects the hands and fingers. It causes one or more fingers to bend into the palm of the hand. It can affect one or both hands and it can sometimes affect the thumb.

Dupuytren's contracture occurs when the connective tissue in the palm thickens. Often the tissue thickens in one small area first and a “nodule” forms (a small, hard lump about 0.5-1cm) under the skin of the palm. The nodule sometimes feels tender to begin with, but this usually passes.

The nodules are non-cancerous (benign) and the condition is not life-threatening for those who develop it, although it can be a nuisance to live with.

Over time, the nodules can extend and form cords of tissue. These cords can shorten (contract) and, if the cords run along a finger or thumb, they can pull it so it becomes bent towards the palm. These contractures are often mild and painless, but they can get steadily worse over time.

Sometimes, the term Dupuytren’s disease (palmar fibromatosis) is used instead of Dupuytren’s contracture, because not everyone with the condition will develop contractures.

Read more about the symptoms of Dupuytren's contracture and diagnosing Dupuytren's contracture.

Why it happens

The exact cause of Dupuytren's contracture is unknown, but it’s thought to be related to your genes as it often runs in families.

If you have the gene that causes Dupuytren’s contracture, other factors such as diabetes, smoking and certain medications (for example, medication for epilepsy) may activate the condition. However, it is not clear how significant these factors are.

Read more about the causes of Dupuytren's contracture.

Who is affected

Dupuytren's contracture is fairly common. It can affect both sexes, but affects men more than women. The condition usually occurs during later life, although cases have been reported in children. Most cases occur in men over 50 and women over 60.

The condition seems to be more common in people of North European descent. It is thought that the gene associated with the condition was brought to the UK by the Vikings.

Preventing Dupuytren's contracture

As the exact cause of Dupuytren's contracture is unknown, it may not be possible to prevent the condition.

However, if you are at risk of developing the condition – for example, if you have had it in the past, or if you have a family history of it – stopping smoking (if you smoke) may help reduce your risk.

Treating Dupuytren's contracture

Many cases of Dupuytren's contracture are mild and don't need treatment. Treatment may be helpful if the condition is interfering with the normal functioning of your hand.

Non-surgical treatments include radiation therapy and injections with a medication called collagenase.

Alternatively, a minor procedure that involves using a needle to cut the contracted cord of tissue (needle fasciotomy) may be used in the early stages of the condition.

In more severe cases, surgery can help restore hand function. The two most common surgical techniques are:

  • open fasciotomy – where the shortened connective tissue is cut to relieve tension
  • fasciectomy – where the shortened connective tissue is removed

Surgery for Dupuytren's contracture cannot always fully straighten the affected finger or thumb and the contracture can recur after surgery. If a contracture does recur, further surgery may be possible.

Having surgery to remove the first nodule that appears will not stop the condition from progressing, as this will not stop the condition from occurring elsewhere in the palm. Therefore, it is usually best to avoid surgery until a contracture that interferswith use of the hand develops.

Read more about treating Dupuytren's contracture and recovering from Dupuytren's contracture surgery.

Ongoing research

Some treatments have been suggested for Dupuytren’s contracture for which there is not enough medical evidence to support their use.

For example, the National Institute for Health and Care Excellence (NICE) does not recommend the use of vitamin E cream or ultrasonic therapy. Trials into other possible treatments are currently underway.

Dupuytren’s contracture often runs in families and genetic research hopes to identify the genes responsible for the condition. This could lead to the development of treatments that prevent contractures occurring in the first place.

Symptoms

The first symptom of Dupuytren's contracture is usually the growth of small lumps of tissue called nodules on the palm of your hand.

You may also notice:

  • unusual dimples on your palm
  • thickening of the skin on your palm
  • tenderness around your palm

Over time, usually months or years, bands of contracted (shortened) tissue called cords can develop in your hand and you may find that you cannot straighten your fingers as much as you used to be able to.

The ring finger is most commonly affected by Dupuytren's contracture, followed by the little finger and then the middle finger. In rare cases, the condition also affects the toes and the soles of the feet.

The condition can affect one or both hands. In cases where only one hand is affected, problems usually develop in the right hand, regardless of whether you are left- or right-handed.

As Dupuytren's contracture progresses, your fingers may eventually be pulled into a permanently bent position. This can make it difficult to perform activities such as swimming, playing a guitar or shaking someone's hand.

When to seek medical advice

You should see your doctor if you think you notice the symptoms of Dupuytren's contracture. They can examine your hand and they may refer you to a hand specialist who can assess whether treatment is necessary.

Read more about diagnosing Dupuytren's contracture.

Causes

Dupuytren's contracture occurs when bands of shortened connective tissue prevent you from fully extending your finger. It is not known why this happens.

However, research has shown there are several factors that make it more likely to develop.

Genetics seems to be the most significant factor, as between four and seven in every 10 people with the condition have a family history of the condition.

Genetics

Due to the significant number of people with Dupuytren’s contracture who have other family members with the condition, it is thought that the condition is an autosomal dominant disorder that can be passed on to you from your parents. Autosomal dominant means that you only need to inherit the gene that causes the condition from one of your parents, rather than both of them.

Dupuytren's contracture is also more common in people of northern European descent, which suggests genes play a role in the condition.

Read more about genetics and genetic inheritance.

Other possible factors

There are a number of health problems that may also increase your chances of developing Dupuytren’s contracture.

  • diabetes – a long-term health condition that causes a person's blood sugar level to become too high
  • treatment for epilepsy with medications called anticonvulsants
  • heavy drinking or smoking

However, many people with Dupuytren’s contracture are not affected by these problems and some studies have suggested the link between them and Dupuytren's contracture is not significant.

A previous injury to the hand – such as a broken wrist – has also been associated with an increased risk of Dupuytren's contracture, but it is not clear how this may lead to the condition.

Dupuytren's contracture is generally not thought to be related to manual work or using vibrating tools, although some recent studies have suggested there may be a link.

Diagnosis

If you see your doctor because you think you may have Dupuytren's contracture, they will examine your palm and hand for signs of the condition.

Characteristic signs of Dupuytren's contracture are:

  • lumps of tissue (nodules)
  • dimples or pitted marks
  • thickened skin
  • bent fingers

Dupuytren’s contracture affects everyone differently, so you will be asked about any specific symptoms you have and any problems with carrying out daily activities. Some people are troubled by quite a minor deformity while others are able to cope with a major one.

If you are unable to fully extend one of your fingers, your doctor may refer you to a specialist at a local hand surgery unit for further assessment and any necessary treatment.

Assessing the need for treatment

If your finger is curling into your palm, the amount of deformity will be measured to determine the severity of the condition.

In mild cases, no treatment may be recommended because there is a chance the condition won't get any worse. If the condition is more severe, treatment with medication or a minor procedure called a needle fasciotomy may be recommended.

In the most severe cases, surgery to correct the problem may be recommended.

Read more about treating Dupuytren’s contracture.

Treatment

Treatment for Dupuytren's contracture is usually only required if the condition affects the function of your hand. Many cases are mild and don't need to be treated.

The treatment used will largely depend on the severity of the condition. In milder cases that require treatment, non-surgical treatments or a minor procedure called a needle fasciotomy may be recommended.

For more severe cases, surgery is an effective and widely used treatment. The two most common surgical procedures are a fasciectomy and an open fasciotomy.

These treatments are described in more detail below.

Non-surgical treatments

Non-surgical treatment options for Dupuytren's contracture include radiation therapy and a relatively new medicine called collagenase clostridium histolyticum. These are generally most effective if used before the condition becomes severe.

Radiation therapy

In 2010, the National Institute for Health and Care Excellence (NICE) issued guidance about the use of radiation therapy to treat Dupuytren’s contracture. Radiation therapy aims to prevent or delay the need for surgery.

Radiation therapy involves aiming controlled doses of high-energy radiation (usually X-rays) at the nodules and cords in your hand.

The radiation doses are spread over several consecutive days. After a few weeks, the treatment can be repeated if necessary.

It is not known exactly how radiation therapy works, but it is thought the radiation affects the development and growth rate of fibroblasts in your hand. Fibroblasts are cells that produce and release collagen (the protein that forms the main part of the body’s connective tissue).

In one of the studies reviewed by NICE, the symptoms of Dupuytren’s contracture had improved in over half of the hands that were treated after one year. In another long-term study, two-thirds of people had some degree of symptom relief after 13 years.

Possible side effects of radiation therapy include dry skin, flaky skin and slight thinning of the skin.

Radiation therapy is still being developed as a treatment for Duypuytren’s contracture and it may not be suitable for everyone. If you are offered radiation therapy, you should be aware of the uncertainty about its effectiveness and the possible – although very small – long-term risk that radiation may cause cancerous tumours.

Collagenase clostridium histolyticum

Collagenase clostridium histolyticum is a fairly new medicine for Dupuytren's contracture that can be injected into cords in the palm of your hand. The medicine contains special proteins that can weaken the cords.

After having the injection, you return to your doctor 24 hours later, and they will straighten your bent finger and stretch it out for 10 to 20 seconds. This breaks the cord and should help increase the range of movement in your bent finger.

Do not attempt to straighten your finger yourself within the first 24 hours, or squeeze or press the cord. Keeping your finger bent encourages the injected medicine to stay in the cord, which is where it needs to be.

If the first injection is not effective, you can have up to three injections in the same cord, with one month between each injection.

In one study that looked at collagenase clostridium histolyticum, the injections were effective in nearly two-thirds of people treated.

The most common side effects occur around the site of the injection and include swelling, bruising, bleeding and pain. These should improve within a week or two. Less common side effects include feeling sick or dizzy.

As with radiation therapy, collagenase clostridium histolyticum is still a relatively new treatment and the long-term effects are unknown. It may also not be widely available.

Needle fasciotomy

A needle fasciotomy is also known as a needle aponeurotomy or a percutaneous needle fasciotomy (percutaneous means "performed through the skin").

It is usually performed as an outpatient procedure. This means you will not need to be admitted to hospital. You will be given a local anaesthetic that will numb your hand without making you lose consciousness.

During the procedure, a sharp blade or a very fine needle will be inserted into the fibrous bands in the palm of your hand or your fingers. The blade or needle will be used to divide the cord under your skin.

By dividing the thickened tissue, your surgeon will release the tightness in your hand that is forcing your finger to bend. The benefits of needle fasciotomy include:

  • your fingers are less deformed
  • you recover more quickly compared to more extensive surgery
  • it is suitable for people who are unable to have more extensive surgery, such as the very frail or elderly
  • it has a low risk (around 1%) of complications

However, the rate of reoccurrence for Dupuytren’s contracture is very high, as many as 60% of people who have a needle fasciotomy experience Dupuytren’s contracture again within three to five years.

Open fasciotomy

An open fasciotomy is sometimes used to treat more severe cases of Dupuytren's contracture. The procedure is more effective in the long-term than a needle fasciotomy, but it is also a more extensive operation and therefore carries some additional risks (see below).

Like a needle fasciotomy, an open fasciotomy will be carried out as an outpatient procedure under local anaesthetic. The surgeon will make an incision in the skin of your hand so they can gain access to the connective tissue underneath. They will then cut the thickened connective tissue to divide it up, allowing you to straighten your fingers.

After the surgery has finished, the cut on your hand is sealed with stitches and a dressing is applied. The recovery time for an open fasciotomy is slightly longer than that of a needle fasciotomy because the wound will need time to heal.

Following the procedure, it is likely that you will need to make another appointment to have your stitches removed and you may be left with a small scar.

Fasciectomy

A fasciectomy involves removing the thickened connective tissue. There are three variations of the procedure:

  • partial fasciectomy – where only the affected connective tissue is removed; this is the most commonly used type of surgery for Dupuytren’s contracture
  • segmental fasciectomy – where one or more small cuts are made in the skin, through which small segments of connective tissue are removed
  • dermofasciectomy – where the affected connective tissue is removed along with the overlying skin (which may also be affected by the disease) and the wound is sealed with a skin graft (where healthy skin is removed from another part of the body and used to cover the area of skin loss in your hand)

A fasciectomy will usually be carried out under general anaesthetic. This means you will be unconscious throughout the procedure and unable to feel pain. In some cases, regional anaesthetic may be used. This is where local anaesthetic is injected into the nerves near your neck, to numb your whole arm, but you remain conscious.

During the procedure, an incision will be made in your hand and the affected connective tissue will be removed. If it is necessary to seal the wound using a skin graft, your surgeon will take a graft from an area of your body that is usually covered by clothing, such as your upper arm, the front side of your elbow or your groin.

A fasciectomy is a more extensive operation than a fasciotomy, so the risk of complications is slightly higher, at around 5% (see below). However, the results are longer lasting. For example, the rate of reoccurrence of Dupuytren’s contracture following dermofasciectomy may be as low as 8%.

Read about plastic surgery techniques for more information on skin grafts.

Surgery risks

If your surgery is complex and extensive, your risk of developing complications will be greater than if you have a more minor procedure.

For needle fasciotomy, the rate of complications is low, at around 1%. For fasciectomy, studies have found complication rates to be higher, from around 5%. Some possible complications are listed below:

  • splitting the skin with the needle during a needle fasciotomy
  • damage to the nerves supplying sensation to your fingertips – the nerves can be repaired, but it is unlikely the fingers will recover their full sensation
  • joint stiffness – this can be helped with hand therapy (see recovering from Dupytren’s contracture for more information)
  • wound failure – the wound or graft failing to heal (more likely to occur if you smoke)
  • infection of the wound – this will usually be treated with antibiotics
  • haematoma – a blood-filled swelling that forms as the wound heals, usually in the palm; it can be drained to reduce the swelling
  • scarring
  • complex regional pain syndrome – a rare complication that causes the hand to become painful, stiff and swollen after surgery; it usually resolves itself within a few months, although sometimes it can be permanent.
  • finger loss (although this is very unlikely)

Discuss the risks of the surgical procedures used to treat Dupuyten’s contracture with your surgeon.

Read more about recovering from Dupuytren's contracture surgery.

Recovery

Recovering full or partial function of the hand following hand surgery for Dupuytren’s contracture can take a long time. Generally, the more extensive your surgery, the longer your recovery time.

It's important to discuss your recovery and any aftercare procedures that you may need with your specialist before having surgery.

Hand therapy

After surgery, you may need specialised hand therapy to help improve the function and range of movement of your hand. For example, you may need to have:

  • physiotherapy – this could involve a number of techniques to help improve your range of movement, including massage, manipulation, exercise, electrotherapy and hydrotherapy
  • occupational therapy – if you are struggling with everyday tasks and activities, either at work or at home, an occupational therapist will be able to provide you with practical support to make those tasks easier

How long you will need to have treatment or assistance for will depend on the type of surgery you have had. For example, you may need hand therapy for up to six months after more extensive procedures.

Splinting

Splinting usually involves bandaging your fingers to a plastic strip while they are in the straightest position you find comfortable. Splinting may initially be recommended all day before being used only at night, and then not at all.

Splinting is not currently a standard procedure and some specialists prefer not to use splints. When splints are used, there is often wide variation in the length of time they are used for, the position of the fingers and how much force is used to keep the fingers straight.

Some specialists believe that splints can positively influence the way that scar tissue forms after surgery, so that the scar doesn't contract and cause the condition to return. Others believe that splints can cause unnecessary pain, joint stiffness and swelling (oedema), so prefer not to use them.

Several research studies have been carried out to try to determine whether or not using splints is effective in the recovery of Dupuytren’s contracture.

One study found that there was no difference between the range of hand movement experienced by a group of people who were routinely splinted after having types of surgery called a fasciectomy or a dermofasciectomy and a group who received hand therapy and were only splinted if contractures occurred.

Driving

After having hand surgery, you can start driving as soon as you feel confident enough to control the car safely. This will usually be after about three weeks, but it may be longer if you have had a skin graft.

Work and sport

When you will be able to return to work will depend on the nature of your job and the type of operation you have had.

If you do heavy manual work, you may not be able to return to work for six weeks after having a skin graft. If you work in an office, you may be able to return to light duties a few days after having a fasciotomy. The same advice applies to sport.

Recurrence

Surgery can help improve hand function in people affected by contractures, but it does not stop the process that caused the contracture to develop in the first place. Therefore, there is a chance the condition may return in the same place or it may reappear somewhere else after treatment.

Recurrence is more likely to occur in younger people, people who had a severe contracture and people with a strong family history of the condition.

The chances of the condition returning after surgery also depend on the specific procedure you had. Dupuytren's contracture recurs in more than half of people who have a type of minor procedure called a needle fasciotomy, but only about one in three people who have a fasciectomy. A dermofasciectomy is associated with the lowest risk of recurrence, with the condition reappearing in less than one in 10 people after the procedure.

The experience of the surgeon who carries out the procedure may also influence the chance of recurrence.

Peter Revell-smith

Peter Revell-Smith, 82, from London, first noticed something wrong with his little finger about 10 years ago. He recently had something done about it.

"It was about 10 years ago when I realised something strange was happening to the little finger on my right hand. Over the next few years it became more and more bent and ended up at a right angle to the rest of my hand. It didn’t hurt, but it gradually interfered with everyday activities. It was especially awkward when I put my hand in my pocket!

"My doctor referred me on to a hand consultant. He diagnosed Dupuytren’s contracture. I thought he would say there was nothing he could do about it, so I was delighted when he said he could perform a small operation that would straighten it out.

"I went into hospital as a day patient. I had an open fasciectomy to cut the cord that was causing the problem. The operation went smoothly and it felt uncomfortable rather than painful.

"I was sent home all bandaged up. I had to keep my arm in a sling for about two weeks. I had to keep it dressed for around three weeks in total and I still wear a splint at night.

"I am delighted with the results. I couldn’t drive for a few weeks but was back on the golf course after about five weeks which was sooner than I expected."

Content supplied by NHS Choices