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Dupuytren’s Contracture

Article
Bone, Muscle, & Joint
Diseases & Conditions
Contributed byKrish Tangella MD, MBAMay 23, 2018

What are the other Names for this Condition? (Also known as/Synonyms)

  • Dupuytren’s Constricture
  • Morbus Dupuytren
  • Old Man’s Claw Hand

What is Dupuytren’s Contracture? (Definition/Background Information)

  • Dupuytren’s Contracture is a common deformity of the hand characterized by an abnormal thickening of the fibrous tissue layer, beneath the skin of the palm and fingers. The fibrous tissue layer beneath the skin, is known as the fascia
  • This condition predominantly affects the ring finger, followed by the little, middle, and index finger. It progresses slowly, usually over a number of years
  • Currently, the underlying cause of Dupuytren’s Contracture is unknown. It is not a condition that is caused by an injury, or repetitive use of the hand. However, studies have indicated that this disorder may have a genetic component
  • Treatment measures associated with this hand deformity includes both non-surgical and surgical methods

Who gets Dupuytren’s Contracture? (Age and Sex Distribution)

  • Dupuytren’s Contracture may occur in individuals of all age, race, ethnic groups, and gender
  • Individuals, over the age of 40 years have the highest rate of incidence of this condition
  • Men are more likely to develop Dupuytren’s Contracture, than women
  • Individuals of certain north European descent, seem to be affected more than other racial and ethnic groups

What are the Risk Factors for Dupuytren’s Contracture? (Predisposing Factors)

Common risk factors associated with Dupuytren’s Contracture include:

  • Individuals, over the age of 40 years, especially men
  • Individuals with certain geographical ancestry (northern European decent), such as English, Irish, Scottish, French, Dutch, Swedish, Norwegian, and Finnish, all have an increased risk of developing Dupuytren’s Contracture
  • A genetic component may be involved, hence those with a positive family history may have a higher risk
  • Smoking increases the risk
  • Excessive consumption of alcohol may lead to its development
  • High blood glucose levels that result either from an insulin secretion deficiency (diabetes type I), or an insulin resistance in the body (diabetes type II)
  • Seizure (epilepsy) disorders is a risk factor for Dupuytren’s Contracture

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Dupuytren’s Contracture? (Etiology)

Currently, the underlying cause of Dupuytren’s Contracture is unknown. However, individuals with a family history of this condition may be more likely to develop this hand deformity.

  • It is speculated that the condition is associated with an autoimmune reaction (when the immune system attacks one’s own body tissues)
  • Dupuytren’s Contracture often ensues in conjunction with conditions that lead to contractures in other parts of the body
    • It can be associated with Ledderhose disease, characterized by inflammation and thickening of fascia tissue on the sole of the foot
    • It can also be associated with Peyronie’s disease, a rare scarring condition of the penis

What are the Signs and Symptoms of Dupuytren’s Contracture?

Sign and symptoms of Dupuytren’s Contracture include:

  • Thickening of the skin at the palm of the hand: One or more, small, painless nodules or lumps may develop on the palms of the hand. The lump may be sensitive to touch, but most oftentimes are painless
  • The condition typically progresses slowly, over years. Infrequently, it has the potential to develop in a time span of weeks to months. Some individuals experience symptoms that advance gradually, while others characterize the symptoms as ‘rapidly starting and stopping’
  • Over time, the nodule will thicken into what is described as a “cord-like band”, extending from the palms towards the fingers
  • Unusual bending or flexing of one or more fingers, towards the palm. The fingers may stay in a bent position. Tightening of these cords may lead to the fingers being pulled towards the palm of the hand
  • Difficulty extending and straightening the fingers. In most severe instances, straightening the fingers can become impossible, complicating everyday activities
  • Either one or both hands may be affected; often, one more severely than the other
  • It is most common for the ring finger to be affected, followed by the little (pinky), middle, and index fingers

How is Dupuytren’s Contracture Diagnosed?

The healthcare provider may use a thorough physical examination and other tests, to help diagnose Dupuytren’s Contracture. Such a diagnosis would involve:

  • Close examination of the hands; comparing both hands to check for any signs of puckering on the skin of the palms
  • The physician may also test the range of motion of the fingers, to determine if there is any restricted/limited motion
  • Tissue biopsy of the hand nodules may also be performed
  • In addition to this, a complete medical history can aid in arriving at a definitive diagnosis

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Dupuytren’s Contracture?

A few complications of Dupuytren’s Contracture could include:

  • Loss of function of the hand, resulting in an inability to perform even certain basic functions and simple tasks, such as:
    • Opening one’s hand
    • Gripping large objects
    • Slipping hands into one’s pockets
  • Degeneration of the contracture, possibly resulting in distortion of the hand
  • Surgical treatment induces a risk of injury to blood vessels and nerves during the procedure. As with all surgical procedures, there is an increased risk of infection as well

How is Dupuytren’s Contracture Treated?

The treatment measures for Dupuytren’s Contracture include both non-surgical and surgical interventions.

Nonsurgical treatment measures may include:

  • Non-steroidal anti-inflammatory oral medications, such as indomethacin and naproxen, may be used to help decrease the pain and swelling
  • Complete immobilization of the hand with a cast may be required, to restrict movement
  • Corticosteroid injections help provide temporary relief of symptoms, and in improving the range of motion. It is important to note that corticosteroid injections only give temporary relief. Prolonged episodes of such injections, may injure the joints in the long-run
  • Ultrasound treatments are advantageous for individuals with persistent soreness
  • Recently approved nonsurgical treatments by the (US) federal drug administration are enzyme injections administered by a surgeon, trained in this method. In this method a small dose of enzyme is directly injected into the affected tissue, resulting in the breaking down of the tough connective tissues. Three injections are administered over a period of time. This can improve the individual’s range of motion, without the need for a surgery. The side effects of this treatment may include:
    • Swelling
    • Pain
    • Itching
    • In rare cases, a rupture of the tendon can occur
  • Percutaneous needle fasciotomy is a minimally-invasive nonsurgical technique, also performed by a surgeon trained in this method. Performed under a local anesthetic, an orthopedic device (a hypodermic needle) is inserted through the skin. It is used to break the damaged contractive connective tissue. The goal is to restore normal function of the hand and fingers
  • Needle aponeurotomy for Dupuytren’s Contracture, (also known as needling), involves the insertion of a hypodermic needle through the skin to rupture and “break” the cord of the diseased tissue
    • Contractures will often persist, but the procedure can be repeated
    • It can be performed on several fingers during the same time period 
    • Very little physical therapy is required after needling
    • The needle can only be administered in certain locations in the finger, due to the possibility of nerve or tendon damage
  • Physical therapy: After the signs and symptoms have abated, it is important to begin some light exercises. Physical therapy may help restore strength, as well as improve flexibility, in the muscles

Surgical treatment measures may include:

  • Total fasciotomy for Dupuytren’s Contracture: Total fasciotomy, also known as fasciectomy, is a minimally-invasive procedure that involves the surgical excision of all of the damaged fascia and sometimes, the aponeurosis, in order to relieve pressure (or tension) on the affected area. It is sometimes believed that the aponeurosis (flat sheet of tendon that anchors muscles to bones or other muscles) may be the source of the disorder
  • Partial fasciectomy for Dupuytren’s Contracture: Partial fasciectomy is a procedure that involves the surgical excision of a portion of the damaged fascia, and sometimes of the aponeurosis
  • Segmental fasciectomy for Dupuytren’s Contracture: Segmental fasciectomy is a procedure that involves the surgical excision of only a tiny portion (or segment) of the damaged fascia
  • Dermofasciectomy for Dupuytren’s Contracture: It is a surgical procedure that involves surgical excision of the entire damaged fascia and substantial amounts of the overlying skin. A skin graft is then used to cover the wound, after the surgery

Contingent on the severity of the condition, surgery may be performed to release the contracture as a more invasive option. Restoration of normal finger movement is common post-surgery, followed by specialized physical therapy exercises for the affected hand.

  • Surgically removing the tissue may present a challenge during the early stages, if it is too premature to be identified
  • The diseased tissue has the potential to attach to the skin, increasing the difficulty of removal and probability of recurrence
  • Surgical treatment results in a more ample joint release, than by the needle or enzyme method
  • Skin grafts may be necessary, if a significant amount of attached skin is removed
  • Approximately 20% of patients experience some degree of relapse, in some cases requiring subsequent surgeries

How can Dupuytren’s Contracture be Prevented?

There are no clearly established preventive measures for Dupuytren’s Contracture. However, early detection and treatment of the condition may help individuals achieve a successful outcome. A few preventive measures of Dupuytren’s Contracture could include:

  • Reduce alcohol consumption; avoid smoking
  • Undertake proper treatment of type I diabetes and type II diabetes

What is the Prognosis of Dupuytren’s Contracture? (Outcomes/Resolutions)

  • The progression of Dupuytren’s Contracture can be unpredictable in many cases, with a high rate of recurrence
  • Surgery, followed by rehabilitation, can usually restore the range of motion of the fingers
  • However, approximately half of all cases of Dupuytren’s Contracture may recur, within a span of about 10 years. Hence, it is difficult to predict the prognosis of this condition

Additional and Relevant Useful Information for Dupuytren’s Contracture:

Approximately, 20% of individuals experience recurrence of Dupuytren’s Contracture to some degree, which may require additional surgery or other management procedures.

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Krish Tangella MD, MBA picture
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Krish Tangella MD, MBA

Pathology, Medical Editorial Board, DoveMed Team

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