Dupuytrens Contracture

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Dupuytrens Contracture is a rare hand deformity in which the connective tissue under the skin of the palm thickens and scars. Knots and cords of tissue form under the skin, often pulling one or more of the fingers into a bent position. Though the fingers affected bend normally, they can't be straightened, making it difficult to use your hand. This disease complicates everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands.

Dupuytrens contracture is rarely painful, though sometimes the bumps of tissue on your palm can be sensitive to touch. Men are more likely than women to develop Dupuytrens contracture. It's more common in older adults, usually developing in people in their 50s and 60s. This disease is more common in whites of Northern European heritage. The condition rarely affects people of color.

Symptoms:

Hand contracture

One or both hands affected

Gradually progression hand contracture

Nodular thickening of palms

Dimpling of skin on palms

Fingers drawn into palms

Finger pain

Palm pain

Inability to straighten finger

Dupuytrens contracture usually begins as a thickening of the skin on the palm of your hand. As it progresses, the skin on the palm of your hand may appear dimpled.

A firm lump of tissue may form on your palm. This lump may be sensitive to the touch, but usually isn't painful.

In later stages, cords of tissue form under the skin on your palm. Cords may extend up to your fingers. As these cords tighten, your fingers may be pulled toward your palm, sometimes severely. The ring finger and the little finger are most commonly affected, though the middle finger may also be involved. Only rarely are the thumb and index finger affected.

It often affects both hands, though one hand is usually affected more severely than the other.

This disease usually progresses slowly, over several years. Occasionally it can develop over weeks or months. In some people it progresses steadily and in others it may start and stop. However, Dupuytrens contracture never regresses.

Causes:
The precise cause of Dupuytren contracture is not known. However, it is known that it occurs more frequently in patients with diabetes mellitus, seizure disorders, and alcoholism.

It can be inherited. In medical terms, the inherited form is transferred in the family as a so-called autosomal dominant trait with incomplete penetrance and partial sex-limitation. This means that the gene for Dupuytrens contracture is not on an X or Y chromosome (sex chromosome) but on one of the other 44 chromosomes. Consequently, one version of the gene is enough to cause the disorder, but not everyone who has the gene has the disorder and the disorder is most frequent in males.

Treatment:
Many people with this disease never require treatment. It often progresses slowly and has little impact on your ability to use your hands for everyday tasks. If you aren't experiencing pain or disability, you may choose to wait and see if it progresses. Your doctor may ask you to come in for checkups every few years, usually to conduct the table top test and monitor any progression of Dupuytrens contracture in your hands. Or, your doctor may ask you to try the table top test at home on your own and make an appointment if you notice your condition is worsening.

Surgery is reserved for people who experience pain and disability from the disease. Doctors recommend this approach because no cure exists for Dupuytren's contracture. While surgery can improve hand function, it doesn't necessarily prevent a recurrence of the disease. Sometimes the disease returns to the same spot on the hand, other times it reappears in other places on the hand.

. . . Types of surgery
What type of surgery you undergo for Dupuytren's contracture depends on factors such as your age, the degree of contracture in your fingers, and the condition of the skin and bones of your hand. Types of surgical procedures include:

Releasing cords of tissue Subcutaneous fasciotomy is used in people who can't undergo more extensive surgery or prefer to avoid the risks of an extensive surgery — for instance, older people and people in poor health. In this procedure, a surgeon severs the cords of tissue under the skin. It can be an open procedure, where the surgeon cuts open the skin with a scalpel. Or it can be performed as an outpatient procedure using a needle to gain access to the cords of tissue. Dupuytrens contracture is likely to recur after subcutaneous fasciotomy. Subcutaneous fasciotomy works best when the disease is limited to the palm of the hand, since the procedure can injure nerves in the fingers.

Partial tissue removal Partial fasciectomy is the most common procedure for Dupuytren's contracture. During partial fasciectomy, the surgeon removes as much of the diseased tissue as possible. Surgeons can't always remove all of the diseased tissue, since it can be difficult to identify tissue in very early stages of the disease. Diseased tissue may also attach to the skin, making it difficult to remove. For this reason, it's common for Dupuytren's contracture to recur after partial fasciectomy, though it's usually less severe and may not require additional surgery.

Complete tissue removal with skin grafting Younger people and those with the highest chance for recurrence might consider complete fasciectomy to completely remove the tissue on the palm of the hand. The diseased tissue usually attaches to the underside of the skin on your palm and fingers, so it may be necessary to remove the skin in order to completely remove the tissue. The removed skin can be replaced with skin from another part of your body. Recurrence is rare after complete fasciectomy. However, this procedure carries the highest risk of complications, including finger stiffness or an inability to bend the fingers. This can be more disabling than the original condition.

Finger amputation Some people experience recurrent Dupuytren's contracture despite multiple surgeries and may consider amputation. Amputation surgery is most commonly used to remove the little finger.

All surgeries carry risks of bleeding and infection. Discuss any concerns with your doctor.

Depending on the extent of your surgery, you may require therapy to help speed your recovery after the procedure. Less-invasive procedures may require four to six weeks of therapy and more invasive surgery could require three to six months of therapy. Therapy usually involves exercises to improve the ability to move your fingers.

. . . Nonsurgical options
A number of nonsurgical options have been proposed, including medications and radiation therapy to the hand. Unfortunately none has proved helpful. Cortisone injections may ease the pain of a tender nodule, but usually doesn't affect the progression of the disease.

Researchers are currently investigating enzyme injections for Dupuytren's contracture. Promising results have shown that enzymes injected under the skin can break down the knots and cords of tissue. Ongoing clinical trials will show whether this can prevent this disease from recurring. Until then, enzyme injection is considered experimental and is only available at a few medical research facilities.

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