What is Dupuytren’s Contracture?
Dupuytren’s contracture is a state in which the hand and fingers gets affected. This condition forces the fingers to bend inside in the direction of palm. Dupuytren’s contracture(1) could occur on one hand or on the both the two hands, which is termed as unilateral or bilateral. This condition is caused when the tissue of the palm of the hand shrinks and gets smaller in the size permanently. This creates difficulties in fully opening out the palm of the hand and stretching the fingers out.
About 20% of men over the age of 60 get affected with Dupuytren’s contracture. Frequency of men getting affected is slightly more than women.
Causes and Risk Factors of Dupuytren’s Contracture
- Dupuytren’s contracture is seen more commonly after 40 years of age.
- Women get less affected than men.
- A common risk factor is diabetes.
- Epilepsy(2) also could be a risk factor.
- Consumption of tobacco or alcohol could also be the cause for developing the state of Dupuytren’s contracture.
- The condition of Dupuytren’s contracture may also be linked to family history.
Signs and Symptoms of Dupuytren’s Contracture
- Commonly the ring finger gets affected followed by the index, middle, and little fingers.
- The affected palm develops thickened scar tissue and causes difficulty in straightening the fingers.
- Development of small nodules in the affected palm.
- Generally one of the fingers bends first and then others may get affected.
- Thickening of the skin of the palm.
- The condition of Dupuytren’s contracture is generally painless.
Treatment of Dupuytren’s Contracture
Dupuytren’s contracture is a condition, which could develop slowly without pain with just a small compromise on the capability of the affected hand. Treatment is not needed in such cases. Only severe cases warrant treatment.
- Treatment is performed by eliminating or breaking apart the cords that force to pull the fingers inside in the direction of the palm.
- The treatment may be performed in many ways depending upon the severity of the symptoms and the patient’s medical history. The treatments may include:
- Needling: A needle is inserted in the skin to break and puncture the cords that are contracting the finger. Generally the contractures may reoccur, but still this method can be repeated. Ultrasound is also being used nowadays to direct the needle at the correct location and to reduce the cases of accidental damage to tendons or nerves. Needling is a technique which does not involve any incision and hence this advantage allows multiple fingers can be treated at the same time. Also very less physical therapy is required for recovery. However, this technique cannot be used in all locations of the finger for fear of damage to a tendon or nerve.
- Enzyme Injections: Collagenase clostridium histolyticum(3) (Xiaflex) injections are also used for treatment of Dupuytren’s contracture. The enzyme in this drug weakens and softens the tense and taut cord in the palm. After a day of the injection, the hand is manipulated in an attempt to break the cord and straighten out the fingers. This is more or less similar to the needling technique other than the fact that manipulation is done the next day and not during or immediately after the injection to allow for the enzyme to act on the cords. One of the disadvantages is that the enzyme injection may initially be more painful. Enzyme injections are to be used only on one joint at a time and there should be at least one month gap between two treatments.
- Surgery: Surgery is considered as the last option, which involves removal of the tissue in affected palm. This process may be challenging due to the difficulty identifying the tissue in the early stages of disease. In some cases the diseased tissue may get attached to the skin, which makes it difficult to remove and also increases the chances of recurrence. The advantage of surgery over other procedures is that it releases the joint completely unlike the needle or enzyme procedures. However, the postsurgical treatment in the form of physical therapy is needed and the recovery time is longer.
- In severe cases, removal of all the tissue is required that is likely to be affected by Dupuytren’s contracture including the skin attached. In such cases skin grafting needs to be done to close the open wound. Since this is the most invasive form of surgery, the recovery time too is the longest and requires months of intensive physical therapy after surgery.
- Physical Therapy may include manipulation, massage, ultrasound, and hydrotherapy.(4)
Exercises for Dupuytren’s Contracture
- Finger Lifts: The affected hand is placed down flat on a table. Exercise only one finger at a time. Take out each finger off the table raising it up for a few seconds. In case of very curled or stiff fingers, it would be better to discontinue this exercise as this could worsen the contracture in fingers.
- Finger Spreads: Dupuytren’s contracture usually affects the pinky and ring fingers but other fingers also could get affected. Each finger is exercised particularly by putting down the hand flat on a table and spreading out the fingers as far as possible and sticking them back in the normal position. This exercise relaxes the fingers and lightens them.
- Grip Exercises: Grip exercises involve picking up objects with the hand to strengthen the grip and maintain dexterity. This exercise is initiated with larger objects first which is easier and then worked all the way down to smaller objects. Squeezing a small towel or a piece of paper into a small ball is also a good exercise for improving grip strength.
- Thumb Exercises: Thumb exercise can be performed by making an “O” shape by joining the tip of the thumb with the tip of each finger individually. Another thumb exercise involves holding the hand out flat in front with all the fingers together. Next step is to spread the thumb out away from the other fingers and then trying to touch the thumb to the base of the pinky finger.