Dupuytren's Disease

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Dupuytren's Disease

Topic Overview

What is Dupuytren's disease?

Dupuytren's (say "duh-pwee-TRAHNZ") disease can change how your hand looks and may make it hard or impossible to use one or more of your fingers.

The disease causes tissue under the skin of the palm of your hand to thicken and shorten. This can pull and bend the fingers in toward the palm. You may not be able to straighten them.

See a picture of a hand with Dupuytren's disease.

The disease gets worse slowly but rarely causes pain. You can treat it, but there is no cure. It may only involve the palm and never affect your fingers, and you may never need treatment.

Dupuytren's disease occurs most often in people ages 50 and older. It often affects both hands and can sometimes affect the soles of the feet.

Dupuytren's disease is also called Viking's disease.

What causes Dupuytren's disease?

The cause of Dupuytren's disease is not known. It might be inherited, because the disease tends to happen in families. The thickening of the tissue may be related to alcoholism, smoking, or diabetes.

What are the symptoms?

You may first see or feel a small lump in the palm of your hand, usually near where your ring finger and small finger meet.

As Dupuytren's disease gets worse, a fibrous cord may develop in the tissue of the palm. The cord may extend to one or more fingers, usually the ring or small finger. The cord may pull your finger toward your palm. This is called Dupuytren's contracture.

At some point you may not be able to move your fingers back or flatten your hand on a table. You may find it hard or impossible to do things like put on gloves, wash your hands, or pick up things.

The disease usually does not cause pain. If you do have pain, it’s most likely when you first get the disease.

How is Dupuytren's disease diagnosed?

Your doctor will look for skin changes on your palm and feel for any knots or a cord. He or she will ask you to move your hand, wrist, and fingers. Your doctor will ask you questions about your family and your symptoms. Your doctor also will ask you about smoking and alcohol use.

How is it treated?

The goal of treatment for Dupuytren's disease is to keep your hand working as best as it can.

  • When you first get the disease, your doctor may have you try finger stretches, a splint, or steroid shots.
  • Some doctors are using a treatment called needle aponeurotomy to separate the tight cords in the palm using a needle.
  • A medicine called collagenase may be injected to try to dissolve some of the tight tissue.
  • Surgery may be recommended if you cannot straighten your fingers or pick things up.

Frequently Asked Questions

Learning about Dupuytren's disease:

Being diagnosed:

Getting treatment:

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  Dupuytren's Disease: Should I Have Hand Surgery?

Cause

The cause of Dupuytren's disease is unknown. Heredity is thought to be a factor, because Dupuytren's disease tends to occur most often in people of northern European descent and among close family members. The thickening of the tissue between the skin and tendons, called the palmar fascia, may be related to one or more things, such as:

Severe forms of Dupuytren's disease may be successfully treated with surgery. But the disease may return. Recurrences may be more common when:

  • The disease develops at an early age.
  • You have Dupuytren's diathesis (an unusual natural tendency to develop a serious form of the disease).
  • You have another disease, such as diabetes.

Symptoms

Dupuytren's disease usually does not cause pain. When pain does occur, it often is early in the disease or may happen if inflammation develops (tenosynovitis).

The first noticeable symptoms of Dupuytren's disease may be:

  • A small knot that may be visible or felt on the palm, usually near the base of your ring or small fingers. The knot is sometimes sensitive to pressure. And it may gradually thicken and begin to pull one or more of your fingers toward the palm.
  • Dimpling that appears on the skin of your palm when the diseased tissue between the skin and tendons (palmar fascia) pulls on the skin.

As the disease progresses, a fibrous, rope-like cord may gradually develop in the palmar fascia and connect your palm to one or more fingers, usually the ring or small finger. The cord pulls your finger toward the palm, which is called Dupuytren's contracture. Eventually you will not be able to flatten your palm on an even surface, such as a table. When it is severe, Dupuytren's contracture can make certain everyday activities—such as picking up items, putting on gloves, or washing your hands—difficult or impossible.

Other conditions that may cause symptoms similar to those caused by Dupuytren's disease include rheumatoid arthritis and work-related injuries.

What Happens

Dupuytren's disease is often not noticed until it becomes severe. The tissue between your skin and tendons, known as the palmar fascia, becomes abnormally thick and fibrous. It is not yet clear what causes this thickening.

There are three general phases of the disease:

  • Early. You may notice a small knot on the palm or at the base of the fingers. There is no pulling or contracture between the fingers and the palm.
  • Active. Dimpling appears on the skin of the palm due to the growth of the thickened palmar fascia. Long, rope-like cords and bands also develop in the fascia, stretching from the palm to one or more fingers. The cord can sometimes be seen and felt.
  • Advanced. The thickened palmar fascia and cord cause a rigid, disabling contracture when the attached finger is drawn towards the palm. Eventually you will not be able to flatten your palm on a table or other even surface. Very severe forms of the disease result in an inability to do routine tasks, such as using silverware.

The disease usually progresses slowly. It most often occurs after age 50. Many people have a mild form that does not cause significant problems. But a rare form called Dupuytren's diathesis occurs at an early age and progresses rapidly.

Dupuytren's disease often develops in both hands of people with the condition, and it most commonly affects the ring and small fingers.

The goal of surgery for Dupuytren's disease is to control the disease and to restore use of the fingers. Even with successful surgery, thickened palm tissue may develop again in the same place or in a new area of the hands. To get hand function back, another surgery is necessary for some people.

What Increases Your Risk

You are at an increased risk of developing Dupuytren's disease if you:

  • Have a family history of the disease.
  • Are of northern European heritage.
  • Are a male.
  • Are over age 50.

You are more likely to get Dupuytren's disease if you have certain diseases or disorders, such as diabetes or alcoholism. Cigarette smoking also increases your chances of getting the disease. You may also have a slightly higher chance of getting Dupuytren's disease if you are being treated for epilepsy.1

When To Call a Doctor

Call a doctor if you notice:

  • Dimples or knots in your palms, especially near the base of your fingers.
  • An inability to flatten your hand, palm down, on an even surface.
  • Pain in your palm or fingers.

Watchful Waiting

Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without using medical treatment. This period may vary from a few days to weeks, months, or years. Dupuytren's disease usually is a slowly progressing disease. If you are still able to move your fingers enough to do daily activities, you and your doctor may choose to continue regular checkups and hand exercises rather than surgery.

Who To See

Your family doctor or general practitioner can diagnose Dupuytren's disease. You may be referred to a specialist, such as a rheumatologist or an orthopedic surgeon.

For treatment of severe cases of Dupuytren's disease, such as when you cannot use your hand for everyday activities, you will be referred to a hand surgeon, an orthopedic surgeon, or a plastic surgeon. A physiotherapist or an occupational therapist, or both, may be part of your treatment team and can teach you how to exercise your hand to help keep your hand and fingers flexible.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Examinations and Tests

Dupuytren's disease develops slowly and may be hard to diagnose in its early stages. Most people do not see a doctor until the disease has progressed. A medical history and physical examination usually provide enough information for your doctor to determine whether you have Dupuytren's disease.

Questions about your medical history for Dupuytren's disease will usually include:

  • Whether any close family members have been diagnosed with Dupuytren's disease or have had any similar symptoms.
  • Your ethnic background.
  • The symptoms and signs you've experienced and for how long.
  • Whether you've noticed similar symptoms on the soles of your feet.
  • Whether you've experienced any pain in your hand.
  • Whether you have a history of smoking or alcoholism.
  • Whether you have other medical conditions, such as diabetes, or if you are being treated for epilepsy.

A physical examination for Dupuytren's disease will usually include:

  • Moving your hand and wrist in various positions.
  • Moving your fingers to check for flexibility.
  • Feeling the palm of your hand for a knot (nodule) or cord.
  • Looking for any skin changes on your hand, such as dimpling or thickening on the palm.

Treatment Overview

The goal of treatment for Dupuytren's disease is to keep or restore hand function. Dupuytren's disease often is a progressive disease, and recurrence is common. As you review your treatment options, consider the following:

  • In the early stages of the disease, you may be able to keep hand function by doing range-of-motion exercises. In some cases, splints are used to try to slow the progress of the disease. But there is not much evidence that stretches or splints help.
  • If you have increasing disability or pain in your hand(s), your doctor may give you an injection. Lidocaine or corticosteroid has usually been used. But even though medicines may be used to treat symptoms, they do not cure or stop the progression of the disease. A medicine called collagenase is now available. When it is injected, it appears to dissolve some of the tight tissue in the hand.
  • If disability continues to progress, you may choose to have surgery to release the contracture of your fingers. A sustained program of physiotherapy and hand exercises may help you regain mobility after surgery. Dupuytren's disease recurs after surgery nearly half of the time, so another surgery may be necessary to keep hand function.
  • Alternative treatments, such as traction devices or exercises, may be used along with surgery to treat Dupuytren's disease.

Initial treatment

Dupuytren's disease often develops slowly. If the tissue between your skin and tendons (palmar fascia) does not thicken to the point that your fingers are bent and cannot be straightened (contracture), you may only need to have your palms checked regularly.

Medicines are not generally used as part of treatment for Dupuytren's disease. But long-acting corticosteroid medicine is sometimes injected directly into the affected area to help manage symptoms of the disease in its early stages, before one or more fingers develop contracture. This medicine may also temporarily help improve hand function.

Ongoing treatment

Treatment for Dupuytren's disease depends on how bad the disease is. You may notice the characteristic nodules in your palms years before your condition interferes with daily activities, or you may never have a reduction in your range of motion.

A long-acting corticosteroid medicine is sometimes injected directly into the affected area to help manage symptoms of the disease in its early stages, before one or more fingers bends toward the palm (contracture).

Collagenase (Xiaflex) injected into the tight cord can help reduce the contracture and improve the range of motion.2

Another medicine under study for relief of Dupuytren's disease is interferon.3

Treatment if the condition gets worse

In severe Dupuytren's disease, the tissue between your skin and tendons (palmar fascia) thickens to the point that your fingers are bent and cannot be straightened (contracture). If you lose the ability to wear gloves or hold objects, or if your hands become painful, a procedure may be done to relieve the contracture. Surgery is most common, but some doctors are now doing needle aponeurotomy.

In needle aponeurotomy (also called percutaneous needle fasciotomy), a local anesthetic is injected into the palm. A needle is used to put small holes in the tight cords. The fingers are then extended to separate the cords. A splint is used to keep the finger straight as it heals.

Surgery can restore mobility to your hands, but Dupuytren's disease recurs often and another surgery may be necessary to keep hand function. After surgery, a sustained program—including using splints, stretching, and doing scar tissue massage and hand exercises—may help you regain mobility and prevent complications or recurrences of the disease.4

Click here to view a Decision Point. Dupuytren's Disease: Should I Have Hand Surgery?

What to think about

Splints sometimes are used after surgery for about 8 to 10 weeks to help restore hand function and prevent symptoms of Dupuytren's disease from recurring. Splints support the palm and help straighten the finger(s) during the healing process. In some cases, splints are worn only at night. But in other cases, splints are worn at all times, except when the wound needs cleaning or during finger exercises. Your doctor will help you learn how and when to wear the splint during recovery.

Prevention

Dupuytren's disease, an abnormal thickening of tissues in the palm, cannot be prevented. It may be a genetic disorder, passed from parents to children.

Home Treatment

Home treatment for Dupuytren's disease focuses on keeping or restoring hand mobility. You may be able to keep your hand function with regular stretching of the involved fingers. Try twice-daily sessions of massaging the hand and then gently stretching the fingers back to relieve tightness and help keep your fingers flexible.

If surgery becomes necessary, home rehabilitation after the procedure may help prevent complications and recurrences of the disease. Try elevating the hand and arm to prevent swelling, wearing a splint to prevent recurrence of contracture, and exercising to keep or regain hand movement.

Splints are used after surgery for about 8 to 10 weeks to help restore hand function and prevent symptoms of Dupuytren's disease from coming back. Splints support the palm and help straighten the finger(s) during the healing process. In some cases, splints are worn only at night. But in other cases, splints are worn at all times, except when the wound needs cleaning or during finger exercises. Your doctor will help you learn how and when to wear the splint during recovery.

After surgery, you can help your scar heal successfully, as guided by your doctor. Scar management may include therapeutic hand massages by a rehabilitation specialist; massaging your hand at home, usually 2 to 3 times a day, following your hand therapist's instructions; and using a splint that keeps pressure against your palm and fingers.

Medications

Medicines are generally not used as part of treatment for Dupuytren's disease. A long-acting corticosteroid medicine is sometimes injected directly into the affected area. This can help manage symptoms of the disease in its early stages, before one or more fingers bends toward the palm (contracture). Corticosteroids may also temporarily help improve hand function.

Medication Choices

Corticosteroid injections may be used to treat symptoms of Dupuytren's disease. But they do not cure or stop the progression of the disease.

What To Think About

Corticosteroids are not a long-term treatment option for Dupuytren's disease, because repeated injections can permanently weaken the tissue and may cause other serious side effects.

Interferon is under study for relief of Dupuytren's disease.3

Surgery

Surgery is the main treatment option for severe cases of Dupuytren's disease. The goal of surgery is to restore the use of your fingers and hand. In most cases, surgery removes the diseased soft-tissue bands that connect your finger joints to the palm, and may involve a skin graft. Total hand function may not be completely restored by surgery. Even with successful surgery, thickened palm tissue may develop again in the same place or in a new area of the hands. Another surgery is often necessary to keep hand function.

You may improve the outcome if you do post-surgical rehabilitation with finger exercises and splints, as directed by your health professional.

Click here to view a Decision Point. Dupuytren's Disease: Should I Have Hand Surgery?

Surgery Choices

Depending on your condition, your surgeon will choose one of the following surgical procedures:

  • Fasciectomy. Removal of the affected tissue (fascia) is the most common procedure.
  • Fasciotomy. The tight cords in the palm are divided through small incisions. This procedure is used for people who cannot have more extensive surgery or general anesthesia.
  • Amputation. Removal of one or more fingers is rarely needed but may be done if earlier procedures have resulted in nerve or vessel damage or the disease has recurred repeatedly.

In rare cases, the middle joint of the finger is fused (permanently joined) to keep it from bending in.

What To Think About

When you are deciding about surgery, think about:

  • The presence of any other health conditions or diseases, such as diabetes.
  • Your willingness to go through post-surgery rehabilitation, which is necessary in order to restore hand function.
  • How bad your loss of hand function is and how you are affected in your daily activities.
  • Your age. The risk of complications and treatment failure are greater with advanced age.

Needle aponeurotomy is a form of fasciotomy that is done as an outpatient procedure with local anesthesia. It has been done for several years in France, but it is just being introduced in Canada and the United States. This procedure may be good for people who cannot have surgery, or as a way to delay surgery. But it only partially corrects pulling or contracture between the fingers and the palm. Also, there is chance of damaging nerves of the adjacent fingers. And there is a high chance the contracture will come back.

Other Treatment

Rehabilitation (treatment by a physiotherapist or occupational therapist) is a necessary step in recovery after surgery on the hand. The goals of rehabilitation are to prevent the buildup of fluid (edema), to manage scarring, and to get back and keep your range of motion. It may include wrapping, splinting, massage, stretching, and exercise. Your therapist may also recommend using bigger grips or handles on equipment so you don't have to bend your fingers as far.

Traction to lengthen and flatten the tissues of the hand is being studied.1

A promising non-surgical form of treatment called enzymatic percutaneous fasciotomy is still under study. In this procedure, a substance (collagenase diluted in calcium chloride) is injected directly into the Dupuytren's cord in order to improve flexibility, mobility, and strength. This study is entering its final phase.3

Other Places To Get Help

Organizations

Canadian Centre for Occupational Health and Safety (CCOHS)
135 Hunter Street East
Hamilton, ON  L8N 1M5
Phone: 1-800-263-8466
(905) 572-2981
Fax: (905) 572-2206
Web Address: www.ccohs.ca
 

The Canadian Centre for Occupational Health and Safety (CCOHS) promotes a safe and healthy working environment by providing information and advice about occupational health and safety.


Canadian Orthopaedic Association
4150 St. Catherine Street West
Suite 360
Westmount, QC  H3Z 2Y5
Phone: (514) 874-9003
Fax: (514) 874-0464
Web Address: www.coa-aco.org

Canadian Society of Plastic Surgeons
Email: information@plasticsurgery.ca
Web Address: www.plasticsurgery.ca
 

The Canadian Society of Plastic Surgeons is a professional organization that promotes plastic surgery and offers educational information to advance the practice of plastic surgery.


References

Citations

  1. Brown AN, Gilkeson GS (2005). Fibrosing diseases: Diabetic stiff hand syndrome, Dupuytren's contracture, palmar and plantar fasciitis, retroperitoneal fibrosis, and Peyronie's disease. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 2, pp. 2093–2108. Philadelphia: Lippincott Williams and Wilkins.
  2. Hurst LC, et al. (2009). Injectable collagenase clostridium histolyticum for Dupuytren's contracture. New England Journal of Medicine, 361(10): 968–979.
  3. Townley WA, et al. (2006) Dupuytren's contracture unfolded. BMJ, 332(7538): 397–400.
  4. Hertling D, Kessler RM (2006). Dupuytren's contracture section of Wrist and hand complex. In D Hertling, RM Kessler, Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 4th ed., pp. 421–422. Philadelphia: Lippincott Williams and Wilkins.

Credits

By Healthwise Staff
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer David Pichora, MD, FRCSC - Orthopedic Surgery
Last Revised February 24, 2011

This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information.