Dupuytren’s Contracture: Unveiling the Constriction of Hand Function
Dupuytren’s contracture refers to the debilitating symptoms that occur as a result of Dupuytren’s disease, which is a benign thickening of the palmar fascia that eventually forces the fingers to bend permanently towards the palm (Soreide, 2018). In initial stages, a small nodule forms in the connective tissue beneath the skin of the hand and as the disease progresses, cord like formations develop and eventually the fingers are unable to be straightened, and remain in a flexed position (Selles, 2022).
Understanding Dupuytren’s Contracture Development
Dupuytren’s contracture develops over time and most commonly affects the ring and little fingers (Soreide, 2018; Dutta, 2020). Diagnosis is made based on patient history, and symptom identification and examination, with early disease signs including dimpling and puckering of the skin on observation and palpable nodules in the palm (Dutta, 2020). The condition is usually painless, so if pain is present then a differential diagnosis of Trigger finger or Osteoarthritis should be considered (Dutta, 2020). While the disease itself is not dangerous, aggressive contractures lead to a significant impact on hand function and therefore an individual’s ability to perform activities of daily living (Rodrigues et al., 2015).
Dupuytren’s is nicknamed ‘Viking’s disease’ due to evidence of a predisposition in people of Northern European descent (Johnson, Pavano & Rodner, 2018). While the root cause remains unclear, genetics, older age (fifth decade or later) and being male increases the likelihood of developing the disease, along with a number of environmental and metabolic factors that are thought to contribute to increased risk (Johnson et al., 2018; Boe, Blazar & Iannuzzi, 2021). Those with familial history, earlier onset, and bilateral involvement, tend to experience more severe and recurring contractures (Boe et al., 2021).
Navigating Treatment for Dupuytren’s Disease
There is currently no cure for Dupuytren’s disease, however a number of conservative and surgical options are available dependent on the severity of the disease and resultant contractures (Soreide, 2018). However, as it is a chronic condition with often a genetic cause, symptoms tend to recur even despite successful treatment (Rodrigues et al., 2015).
Disease progresses over time, and this can vary between patients, with not all patients going on to develop contractures requiring intervention (Boe et al., 2021) Mild and early-stage disease should be monitored closely, with patients presenting with contracted cords requiring more active monitoring as they are more likely to progress (Johnson et al., 2018; Boe et al., 2021). Unfortunately, there is no preventative treatment to date that stops the progression of contractures (Boe et al., 2021).
Exploring Options Beyond the Absence of a Cure
Severe disease with aggressive contractures will eventually require surgical intervention. Expert consensus states that intervention is indicated once contractures develop to greater than 30° at the metacarpophalangeal joint (MCPJ) and 15° at the proximal interphalangeal joint (PIPJ), which can be monitored using the tabletop test (Boe et al., 2021). Surgical options include fasciectomy and dermofasciectomy (skin graft), or minimally invasive alternatives including percutaneous needle fasciotomy, or collagenase (enzymatic digestion) injection (Rodrigues et al., 2015; Soreide, 2018). Evidence regarding the optimal intervention is unclear, however younger patients may benefit from more aggressive surgical options as they are associated with lower recurrence rates (Selles, 2022; Rodrigues et al., 2015; Soreide, 2018).
Post-surgery rehabilitation with a hand therapist is important and aims to reduce the likelihood of symptoms returning and improve functional outcomes (Karam, M., Kahlar, N., Abul, A., Rahman, S., & Pinder, R. 2021). This therapy involves wound management and hand-based exercises, with night-time extension splinting on an as needed basis, to encourage straightening of the affected finger if an extension deficit is present post-operatively (Karam et al., 2021; Soreide, 2018).
Final thoughts on Managing Dupuytren’s Disease and Contracture
If you have signs and symptoms as described above, you may have Dupuytren’s disease. You should seek assistance from a Hand Therapist at Action Rehab to help you understand the disease and disease management options, assess your functional limitations and goals, and develop a treatment plan designed to suit your individual needs.
References:
- Boe, C., Blazar, P., & Iannuzzi, N. (2021). Dupuytren contractures: an update of recent literature. The Journal of Hand Surgery, 46(10), 896-906.
- Dutta, A., Jayasinghe, G., Deore, S., Wahed, K., Bhan, K., Bakti, N., & Singh, B. (2020). Dupuytren’s contracture–current concepts. Journal of Clinical Orthopaedics and Trauma, 11(4), 590-596.
- Johnson, J. D., Pavano, C., & Rodner, C. (2018). Dupuytren’s disease. Essentials of Hand Surgery, 57.
- Karam, M., Kahlar, N., Abul, A., Rahman, S., & Pinder, R. (2021). Comparison of hand therapy with or without splinting postfasciectomy for dupuytren’s contracture: systematic review and Meta-analysis. Journal of Hand and Microsurgery.
- Rodrigues, J. N., Becker, G. W., Ball, C., Zhang, W., Giele, H., Hobby, J., … & Davis, T. (2015). Surgery for Dupuytren’s contracture of the fingers. Cochrane Database of Systematic Reviews, (12).
- Selles, R. (2022). Early-stage Dupuytren’s disease treatment; a promising next step?. The Lancet Rheumatology, 4(6), e377-e378.
- Soreide, E., Murad, M. H., Denbeigh, J. M., Lewallen, E. A., Dudakovic, A., Nordsletten, L., … & Kakar, S. (2018). Treatment of Dupuytren’s contracture: a systematic review. Bone Joint J, 100(9), 1138-1145.
