Dupuytren’s Contracture – An Introduction

Dupuytren’s disease is a condition that affects the palm of the hand, forming contracted cords. It is more common in men and found most commonly in people with a Celtic genetic background (Irish, Scottish, Scandinavian, Northern European), although it is found in people of many different ancestries. There is a genetic predisposition, but the exact mechanism is not known.

 

Dupuytren’s disease affects the connective tissue in the palm known as palmar fascia (normal tissues are shown in Figure 2), which is the tissue that helps stabilize the palm skin. The palmar fascia starts near the wrist, divides into pre-tendonous bands as it goes to the fingers, and then splits into two bands that attach to the natatory ligament and into the sides of the fingers. People with Dupuytren’s disease may also have thickening of the plantar fascia on the sole of the foot which is called plantar fibromatosis. Men with Dupuytren’s disease may also have curvature of the penis, which is called Peyronie’s disease.

Dupuytren’s contracture is a fairly common condition that occurs when the connective tissue under the skin (specifically, the pre-tendonous bands of the palmar fascia) begins to thicken and shorten. As the tissue tightens, it may pull the fingers down towards the palm of the hand. In some individuals, the condition may progress until the involved fingers become disabled.

Who is at risk?

People of northern European descent. There is a strong genetic component to Dupuytren’s contracture, although not all patients are of northern European descent.
Men. The incidence of Dupuytren’s contracture is about seven times higher among men than among women.
People of middle age. Most of the time, Dupuytren’s contracture doesn’t show up until after age 40. However, a very aggressive form may rarely appear in teenagers and children (this is called Dupuytren’s Diathesis).
Diabetics and people taking anticonvulsant drugs for epilepsy.
Signs and symptoms

The first sign is a thickening (nodule) in the palm of the hand that most frequently develops near the base of the ring or little finger. The nodule, which can resemble a callous, is painless but may be tender to the touch. Gradually, a thickened tissue of palmar fascia forms from the pre-tendonous band and becomes a cord. This may extend across a joint, causing a contracture as the cord shortens. The overlying skin begins to pucker (or form pits), and rough cords of tissue extend into the finger. As the process continues, these cords tighten and pull the finger in toward the palm. The ring finger is usually affected first, followed by the little, long and index fingers. The problem is not pain, but the restriction of motion and the deformity it causes. People often mistake the contracted chords of tissue as tendons. The tendons are much deeper, and are usually not involved.

The progress of the disease is often sporadic and unpredictable. Exactly what triggers the formation of nodules and cords is unknown. As the disease progresses, the diseased tissue wraps itself around and between normal tissue. Patients occasionally report rapid progression after a trauma.

Many people do not seek medical care until the contracture is well advanced. Many retired men do not show up in my office until they no longer can fit a golf club into their contracted fingers! The standard treatment for this condition is surgery, which is usually reserved for individuals who have developed deformity as a result of the progressive contracture. Because many nodules do not progress to contracture and because scar tissue from previous surgeries can make excision of recurrent nodules more difficult, surgical removal of isolated nodules is not indicated in most cases.

A good guideline for determining when to consider treatment is the “table top test.” Try to place the palm of your hand completely flat on a hard surface (Figure 3). If you can’t, the contracture has progressed to a point where surgical intervention could be helpful.

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