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Dupuytren's disease / Dupuytren's contracture

What is Dupuytren's disease?

Symptoms of Dupuytren's disease

Causes of Dupuytren's disease

Risk factors for Dupuytren's disease

Prevention / remedies / cures / treatment for Dupuytren's contracture

References

What is Dupuytren's disease?

Dupuytren's contracture on ring finger

Dupuytren's disease (also known as morbus Dupuytren) is a thickening of connective tissue in the palm of the hand. In more severe cases it progresses to Dupuytren's contracture, when one or more fingers bend (contract) into the palm and you cannot straighten them.

About 1 in 6 men in the UK over the age of 65 have some degree of Dupuytren's contracture. Most cases occur after the age of 40, although it can develop in younger adults. In middle age about ten times more men are affected than women, but by the age of 80 the gender distribution is about even. It is most commonly found in people of European descent.

Symptoms of Dupuytren's disease

Dupuytren's disease is most common in the palm of the hand and on the palm side of the fingers. Less frequently, thickened tissue occurs under the skin in other parts of their body, including the knuckles, the soles of the feet, and the penis.

It starts with a thickening of some of the connective tissues under the skin of the palm. If you feel it with your fingers it is like bony lumps. Dupuytren's disease often starts with nodules in the palm of the hand and can later extend to a cord in the finger. It mainly occurs under the skin but above the tendons, where it forms into lumps and bands of thick tissue. This abnormal tissue is similar to scar tissue that forms following a wound.

In later stages you may develop a contracture (bending) of one or more fingers. Usually it affects both hands. The affected finger(s) contract towards the palm and you cannot straighten them fully. The ring finger is usually affected first, followed by the little finger and then the middle finger. The index finger and the thumb are usually spared. It usually takes years for the condition to develop and progress to a contracture.

Dupuytren's contracture is not usually painful. You can feel bony lumps, but they are not painful unless you press them. The main problem is that as the disease develops you cannot use the affected fingers properly as it reduces your ability to grip objects. It is also unsightly and unattractive.

Causes of Dupuytren's disease

Most doctors maintain that the cause of Dupuytren's disease is not known, and this is what they are taught. It is not associated with work environment, vibrating tools or manual work.

Risk factors for Dupuytren's disease

Prevention / remedies / cures / treatment for Dupuytren's contracture

In most cases Dupuytren's disease causes little interference with the use of the hand and does not require treatment. Treatment is needed only if the normal function of the hand is affected - or is likely soon to become affected.

In about 10% of cases, the condition improves or disappears on its own.

Conventional medical treatments

Doctors will recommend treatment if you cannot place your hand flat on a table top, or if your hand's function is significantly affected. A specialist may offer non-surgical or surgical options to try to restore hand function and prevent progression of the disease.

Non-surgical options include splinting or stretching, local steroid injections, collagenase injections, and radiation therapy (usually X-rays). These options have side-effects, are not very effective, and do not tackle the root cause of the ailment. (1,2,3,4,5,6)

Surgical treatments for Dupuytren's contracture include needle fasciotomy and open fasciotomy. (Fasciotomy is cutting the thickened tissue.) Needle fasciotomy (also called needle aponeurotomy or closed fasciotomy) is a quick, minimal-intervention procedure. The specialist pushes a fine needle through the skin over the contracture. The surgeon then uses the sharp bevel of the needle to cut the thickened tissue, using the needle like a saw or plane under the skin. However, as the specialist cannot see the end of the needle there is a risk of damage to nearby nerves and blood vessels. Needle fasciotomy does not remove the thickened tissue but leaves the debris in place. It is not suitable for severe contractures, and the contracture returns in about half of cases within 3-5 years. This procedure is only suitable where the contracture is not close to important nerves in the hand. Open fasciotomy is the more commonly done procedure, when the overlying skin is cut open to expose the thickened tissue and cut it out.

Both procedures are done under local anaesthetic in an outpatient clinic.

References

1. Seegenschmiedt MH, Olschewski T, Guntrum F. Radiotherapy optimization in early-stage Dupuytren's contracture: first results of a randomized clinical study. March 2001. International journal of radiation oncology, biology, physics 49 (3): 785-98. doi:10.1016/S0360-3016(00)00745-8. PMID 11172962.

2. Keilholz L, Seegenschmiedt MH, Sauer R. Radiotherapy for prevention of disease progression in early-stage Dupuytren's contracture: initial and long-term results. November 1996). International journal of radiation oncology, biology, physics 36 (4): 891-7. doi:10.1016/S0360-3016(96)00421-X. PMID 8960518.

3. Betz N, Ott OJ, Adamietz B. Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years. Strahlenther Onkol. 2010 Feb;186(2):82-90. Epub 2010 Jan 28.

4. Thomas A, Bayat A. The emerging role of Clostridium histolyticum collagenase in the treatment of Dupuytren disease. Ther Clin Risk Manag. 2010 Nov 4;6:557-72.

5. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, Smith TM, Rodzvilla J. CORD I Study Group, Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009 Sep 3;361(10):968-79.

6. Morsi Khashan, Peter J. Smitham. Dupuytren's Disease: Review of the Current Literature. Open Orthop J. 2011;5 Suppl 2:283-8. Epub 2011 Jul 28.