Dupuytren’s contracture can cause the fingers to become permanently bent toward the palm. This condition primarily affects the ring, pinky, and, sometimes, the middle fingers in men. It most often begins in the right hand rather than the left, unrelated to hand dominance, though 80% of people will eventually develop it in both hands. When women are affected by Dupuytren’s contracture, it usually appears later in life and is less severe. The exact cause of Dupuytren’s contracture is unknown, though it is assumed to be genetic.
How Dupuytren’s Contracture Occurs
Fibrous connective tissues or fascia runs all throughout the human body. This tissue is similar to tendons but rather than connecting muscle to bone, it surrounds muscles and most other structures, providing flexibility and strength. Dupuytren’s contracture occurs when the fibrous bands of fascia responsible for grip strength, the palmar fascia, begin to thicken and shorten.
The thickened fascia may first appear to be one or numerous hard bumps under the skin of the palm. The affected individual will be able to both see and feel these bumps. The tissue continues to shorten and thicken, eventually becoming several tight bands known as cords. These cords pull on the affected area, and the attached fingers begin to curl towards the palm. When Dupuytren’s contracture has fully matured, it may be impossible to move or extend those fingers. While some people feel pain, the condition more commonly causes aching or itching.
Who it Affects
Dupuytren’s contracture primarily affects men over 50 of Northern European ancestry, hence its common name, Viking’s disease. Several other risk factors may make Dupuytren’s more likely to occur. Those who smoke or consume alcohol in excess are at a higher risk. People with lower-than-average BMI and those who work with their hands are also more likely to be affected by Dupuytren’s contracture. Medications to treat epilepsy, diabetes, liver disease, thyroid problems, elevated cholesterol, and previous hand injuries also appear to increase the risk.
A person with a family history of Dupuytren’s contracture is 60 to 70% more likely to develop the condition — it is the most common inherited connective tissue disorder. Because the exact cause of the disorder is unknown, it is impossible to tell which family members will develop it. The gene markers associated with Dupuytren’s may appear in people who will never have connective tissue problems. They may sometimes appear in a person with no family history of the disorder, though these cases are usually less severe than the inherited variety.
Testing for Dupuytren’s Contracture
There are several ways to test for Dupuytren’s contracture. A doctor can observe and feel the hands themselves or have the patient do a tabletop test: the individual lays their hand palm down on a table. Inability to fully flatten the fingers, along with the characteristic knots and thickened cords, are strongly suggestive of Dupuytren’s contracture. Some people may also require genetic testing, which has confirmation benefits over the tabletop test but also limitations and risks.
Treatment: Limited Fasciectomies
The most common surgical treatments for Dupuytren’s contracture are fasciectomy variations that remove the strips of fascia causing the affliction. Limited fasciectomies are common and require regional or general anesthesia. The surgeon opens the skin and excises the affected cords and fascia. The hand has many neurovascular bundles, so extreme precision is vital to full recovery, which usually takes around six weeks.
A dermofasciectomy is one of the most common procedures for people who have had or are expected to have a recurrence of Dupuytren’s. The procedure is similar to a limited fasciectomy. The surgeon removes the diseased cords and fascia, as well as the overlying skin. A skin graft closes the skin. The recurrence of Dupuytren’s contracture is lower with this method, but there are other complications related to skin grafting.
Treatment: Segmental Fasciectomy
For a less invasive surgery option, some people undergo a segmental fasciectomy. The surgery is “segmental” because the surgeon removes only portions of the afflicted fascia. This is done under regional anesthesia and with small, curved incisions. The surgeon removes small amounts of the fascia until the finger can comfortably extend. In some cases, he or she may place a layer of cellulose between the parts of the cord that remain. Patients are encouraged to begin moving their hands as soon as a day after surgery. They wear extension splints for several weeks after, when not doing physical therapy.
Treatment: Percutaneous Needle Fasciotomy
Percutaneous needle fasciotomy avoids invasive measures by weakening the affected cords through the repeated insertion of a small needle. Once weakened, the doctor snaps the cord by stretching the finger and palm. This method enables the physician to treat multiple areas and fingers at the same time without the risks related to surgery. The treated hands are usable as soon as 24 hours after the treatment, without the need for physical therapy or splints. This method has a higher recurrence rate compared to other treatment options but can be repeated when needed. Care must be taken in selecting where to insert the needle since there is a small risk of damaging a nerve or tendon.
Recently, doctors have begun using the enzyme collagenase to treat Dupuytren’s contracture. The collagenase dissolves and weakens the hardened cords that limit movement of the fingers. The physician injects the serum into the palm or joint and has the patient return in 24 hours. The patient must wear gauze and elevate the hand during this time, to allow the collagenase to break down the tightened cord. After 24 hours, the doctor flexes the hand to snap the now damaged cord. The patient then uses a splint at night and performs physical therapy each day for up to four months.