What is Dupuytren’s Contracture?
Dupuytren’s contracture is a benign, progressive condition where one or more fingers can become locked in a permanently flexed (bent) position. Typically, the condition is not painful however some aching may be present. The main concern with Dupuytren’s is the significant impact on activities of daily living, making tasks such as writing, combing hair, using cutlery and preparing food incredibly difficult. The condition progresses with the fascia on the palmar aspect of the hand becoming abnormally thick. The main function of the palmar fascia is to assist with grip strength. It is most commonly the ring finger that is affected although others can be at times. Recently the term Dupuytren’s Disease has been started to replace Dupuytren’s Contracture in some texts as often the fingers are not fixed in a flexion deformity.
The condition is named after Baron Guillaume Dupuytren, a French anatomist and military surgeon who first described the contracture in 1833. Famously known for being one of Napoleon’s physicians, he first operated on the contracture in 1831 and published his findings in “The Lancet” in 1834 before his death in 1835. The Musée Dupuytren, a medical museum in Paris was named in his honour and contains wax anatomical items and specimens depicting malformations and diseases, part of the famous Pierre and Marie Curie University School of Medicine.
There are three types of Dupuytren’s Contracture, distinguished by their severity and rate of progression.
Type 1 – this is a very aggressive form sometimes known as Dupuytren’s diathesis, it is found in only 3% of sufferers
Type 2 – the most common form of Dupuytren’s, usually affecting the palm only. Contracture can be made worse by manual labour and diabetes
Type 3 – a mild form of the condition, common amongst diabetics or caused by certain medications including anti-convulsants taken by epileptic patients
Who Gets It?
Dupuytren’s Contracture usually occurs in males over the age of 50, although it can affect females as well and incidence increases with age. While the cause is unknown there are some factors that increase the chance of developing the contracture, such as family history, smoking history, increased alcohol intake, diabetes, liver disease, thyroid deficiency, epilepsy and a history of previous hand trauma. Individuals with a strong family history are more likely to develop a more severe case of the disease and also at a younger age. People of Scandinavian or Northern European heritage are also at an increased risk, leading to Dupuytren’s becoming known as the ‘Viking Disease’.
People who are employed as manual workers are more at risk due to the exposure to vibrations and gripping nature of their job role and high load placed through their hands. There is also a link with lower body weight resulting in a higher risk of developing the condition.
How is Dupuytren’s Contracture treated?
In mild cases, if the function of the hand is maintained then the contracture can simply be monitored, with care taken to avoid aggravating activities to try and prevent worsening.
If treatment is required, initially it involves a steroid injection, which can soften the tissue, and then physiotherapy to regain range of movement, muscle strength and dexterity, improving hand function.
The cords may need breaking down, which can be done by inserting needles into the skin, perforating the contracted tissue. Contractures can recur after needling but the process can be repeated if necessary. While the advantage of needling is that it does not require a surgical incision, the risk is the danger of nerves or tendons being damaged on needle insertion and the procedure should only be performed by a specialist.
An enzyme injection of a substance called Collagenase can also be injected into the cords to soften them, leaving them easier to break down and a doctor or therapist can then straighten the fingers. The risks involved are the same as needling, damage to nerves and tendons if cut accidentally. Additional side effects noticed during research included bruising, bleeding, swelling and tenderness over the injection site but also two cases of tendon rupture and one of Complex Regional Pain Syndrome.
Surgery is usually saved for those with advanced disease; however, it remains as the primary medical treatment for Dupuytren’s Disease. Although surgical removal of the contracture provides lasting results, the disadvantage is that it requires a period of physiotherapy afterwards and recovery time can be longer. In severe cases, surgeons can remove all of the tissue in the palm that is likely to be affected by Dupuytren’s and a skin graft may even be required to cover the wound.
Physiotherapy is an important part of the post-operative pathway, usually commencing the day after surgery. The initial priority is education on the management of swelling and scar tissue as well as commencing range of movement exercises, maintaining range of unaffected adjacent joints and performing any splinting that may be required. Once the surgical wound has healed then range of movement and strengthening exercises can be progressed with the goal being to regain full function on fingers and hand.
Physiotherapy assessment and treatment consists of:
- Range of movement at finger joints – both active and passive.
- Range of movement at wrist – both active and passive.
- Assessment of grip strength.
- The Disabilities of the Arm Shoulder and Hand (DASH) Questionnaire is often administered to measure progress.
- Hand and finger exercises to stretch the palmar aspect of the hand and the fingers.
With any of the above treatments, the risk remains that the contractures may return, and complete hand and finger function may not be regained. Splinting and hand therapy may be required for long periods of time.