Dupuytren's contracture
Dupuytren's disease/ Morbus Dupuytren / palmar fibromatosis / Viking hand

Dupuytren's contracture is characterized by the development of hard connective tissue in the palm of the hand and fingers. In the long term this may result in the fingers no longer being able to extend fully.

It is worth noting that this condition almost exclusively affects people with pale skin color. Men are affected more often than women. The symptoms primarily occur in people over the age of 30.

Description of condition

Dupuytren's contracture causes hardening of the connective tissue in the "palmar fascia". This is the flat white sheath located in the palm of the hand around the flexor tendons running to the fingers. The hardening or lumps are called "nodules" (nodule = lump).

As more and more nodules develop, they form into a strand of connective tissue that contracts over time. This pulls the finger into a flexed position, making it impossible to extend. A so-called "flexion contracture" develops.

The nodules develop between the skin and the tendons. The tendons themselves are not involved in the disease process.

The ring and little finger are most often affected, but the symptoms can also occur in other fingers. The symptoms regularly occur in both hands.

Cause and history

The symptoms develop gradually. It starts with slight hardening in the palm of the hand and fingers, which develops into nodules. Over the course of months or years these nodules can turn into hard subcutaneous strands of connective tissue that force the finger(s) into a flexed position.

The cause of Dupuytren's contracture is currently unknown. Inflammation, trauma, new tissue formation and genetic factors appear to play a role. Genetic predisposition is a noticeable factor in some families. There is a family history in approximately 12 % of cases.

The condition is also partially associated with diabetes mellitus. Alcoholics, smokers, patients with hypercholesterolemia or liver problems also have a higher risk of developing Dupuytren's contracture. HIV patients and people who take anti-epileptic medication are also at increased risk.

Signs & symptoms

• Rigid strands of connective tissue and/or hard lumps in the palm of the hand.
  
• The lumps are generally not painful. However, the strands and lumps may cause pain when using the hand.
  
• The strands run over the palm of the hand to the fingers, usually to the ring and little finger (sometimes also to the thumb, index finger or middle finger).
  
• The hand palm and fingers can become bent over the course of months or years. They can no longer extend.
  
• Stiff fingers as a result of the joint capsule on the finger joints withering.
  
• In some cases there will be reduced sensation in the fingers, because a nerve may become impinged by the connective tissue strand.

Diagnosis

There are various ways of categorizing Dupuytren's contracture into grades. One rough categorization is:

• Grade 1: A thickened nodule or strand of connective tissue in the hand palm.
  
• Grade 2: As for grade 1, plus a slight limitation in extension of a finger.
  
• Grade 3: Advanced stage, extension of the finger is severely limited.
  

The curvature of the fingers is measured to gain a more accurate record of the stage of Dupuytren's contracture.

Treatment

As the cause is unknown, treatment is aimed at combating the symptoms.

Physiotherapy
The physiotherapy treatment consists of stretching the contracted strands. This must take place in a controlled manner, in order to prevent additional scars forming as a result of micro trauma.



A night-time splint may be used to improve the extension of the fingers.

Injections
An injection may be administered to "soften" the tissue. The connective tissue strand is then torn off.

Percutaneous fasciotomy
A needle is used to puncture the skin through to the connective tissue strand to cut through the strand. This is performed under anesthetic and has the advantage that it results in minimal scar tissue formation.

Surgery
Surgery may be performed to cut through or remove the affected tissue. Surgery can greatly reduce the pain or nuisance experienced by the patient. The curvature of the fingers is corrected with this surgery. The aim of the treatment is to maintain use of the hand.

Unfortunately, for all treatments, the symptoms will return over time in many cases. There is no cure for Dupuytren's contracture.

Exercises

You can check your symptoms using the online physiotherapy check or make an appointment with a physiotherapy practice in your locality.

References
Alessie, J. & Buijs, M. (2014). Bindweefsel en mobilisatie. Physios. 2014:3:6-15.
Dingemans, A.J., Sonneveld, G.J., Rappard, J.H.A. van & Borghouts, J.M.H.M. (1990). De ziekte van Dupuytren. Ned Tijdschr Geneeskd. 1990;134:2330-4.
Lohman, A.H.M. (2004). Vorm en beweging. Leerboek van het bewegingsapparaat van de mens. Houten: Bohn Stafleu van Loghum.
Nederlandse Vereniging voor Plastische Chirurgie (2012). Richtlijn. Ziekte van Dupuytren. NVPC.
Nugteren, K. van & Winkel, D. (2010). Onderzoek en behandeling van middenhand en vingers. Houten: Bohn Stafleu van Loghum.
Verhaar, J.A.N. & Linden, A.J. van der (2005). Orthopedie. Houten: Bohn Stafleu van Loghum.