Dupuytren’s Contracture

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The human hand is made up of the wrist, palm, and fingers, and consists of 27 bones, 27 joints, 34 muscles, over 100 ligaments, and many blood vessels and nerves…the hand enables us to perform many of our daily activities such as driving, writing, and cooking.

Dupuytrens contracture is characterized by a deformity of the hand in which the joints of one or more fingers cannot be fully straightened. The condition is a disorder of connective tissue, which supports the body’s muscles, joints, organs, and skin and produces strength and flexibility to structures throughout the body. In particular, Dupuytrens contracture results from shortening and thickening of connective tissues in the hand, including fat and bands of fibrous tissue called fascia; the skin is also involved. Dupuytrens contracture often occurs in only one hand, affecting the right hand twice as often as the left. About 80% of affected patients eventually develop features of the condition in both hands.

Dupuytrens contracture typically first appears as one or more small hard nodules that can be seen and felt under the skin of the palm. In some individuals, the nodules remain the only sign of the disorder, and occasionally even go away without treatment. However, in most cases, the condition gradually gets worse. Over months or years, tight bands called cords begin to develop. These cords gradually draw the affected fingers downward so that they curl toward the palm. As the condition worsens, it becomes difficult or impossible to extend the affected fingers. The fourth (ring) finger is most often involved, followed by the fifth (little), third (middle), and second (index) fingers. Occasionally the thumb is involved.

Causes & Symptoms

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Dupuytrens contracture typically progresses slowly, over years. The condition usually begins as a thickening of the skin on the palm of your hand. As it progresses, the skin on your palm might appear puckered or dimpled. A firm lump of tissue can form on your palm. This lump might be sensitive to the touch but isn’t painful. However, in later stages of Dupuytrens contracture, cords of tissue form under the skin on your palm and can extend up to your fingers. As these cords tighten, your fingers might be pulled toward your palm, sometimes severely.

The two fingers farthest from the thumb are most commonly affected, though the middle finger can also be involved. Only rarely are the thumb and index fingers affected. Dupuytrens contracture can occur in both hands, though one hand is normally affected more severely.

The exact trigger that causes the palmar fascia to thicken and contract is unknown, however, potential factors include:

  • Vibration exposure

 

  • Prior hand trauma

 

  • Smoking

 

  • Hyperlipidemia

 

  • Complex regional pain syndrome (CRPS)

 

Other associated difficulties can include the following:

  • Ledderhose disease – This disease creates thickening and shortening of the foot’s deep connective tissue. As the disease progresses, it can cause quite severe pain while walking.
  • Peyronie’s disease – There may be thickening and shortening of tissue in the penis area.
  • Garrod’s pads – The finger joints on the same hand may enlarge and thicken.

Who gets Dupuytren's Contracture?

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The exact cause of a Dupuytrens contracture is not known. However, it is known that it occurs more frequently in patients with diabetes mellitus, and seizure disorders. A Dupuytrens contracture can also be inherited. In medical terms, the inherited form of a Dupuytrens contracture is transferred in the family as known as an autosomal dominant trait, with incomplete penetrance and partial sex-limitation. This means that the gene for a Dupuytrens contracture isn’t on an X or Y chromosome, but on one of the other 44 chromosomes. One version of the gene is enough to cause the disorder, but not everyone who has the gene has Dupuytrens contracture.

A number of other risk factors are believed to increase your risk of Dupuytrens contracture, including:

  • Age – Dupuytrens contracture occurs most commonly after the age of 50.
  • Gender – Men are more prone to develop this disease and to have more severe contractures than are women.
  • Family history – Dupuytrens contracture often runs in families.
  • Tobacco and alcohol use – Smoking is associated with an increased risk of Dupuytrens contracture, perhaps because of microscopic changes within blood vessels caused by smoking tobacco. Alcoholism intake is also associated with this disease.

How Does it Affect You? How Serious is it?

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Treatments in general are meant to help reduce further symptoms associated with many conditions, including Dupuytrens contracture. However, there are several complications that may occur while in the midst of recovering from this condition through certain treatments. These complications include:

 

Recurrence

Recurrence of Dupuytrens contracture is almost guaranteed after treatment for contracture as it is a disease that typically leads to a contracture developing. Therefore, treatment of the symptom does not fully eradicate the underlying problem; over time the problem is likely to return.

Pain

Pain after treatment can occur – up to 20% of patients report significant pain after treating the condition. The hand and fingers are full of nerve endings and prone to developing discomfort after treatment. Typically, the pain resolves with time, but there are some people who have chronic pain or a condition called ‘complex regional pain syndrome’ that can cause ongoing discomfort and disability.

Scar tissue

Scar tissue is a result of any type of invasive treatment. With less invasive treatment, less scar tissue typically forms. With more invasive treatments, more scar tissue can form. Scar tissue is most common after surgical treatment and can ultimately limit future treatment options if and when the contracture returns down the road.

Skin tears

Skin damage is surprisingly common after treatment for Dupuytrens contracture. When this disease pulls the fingers into the palm of the hand, the skin can also tighten and contract. In addition, the skin becomes much less supple and flexible. When a release of the Dupuytren’s cord is performed, the skin may need to be released or it may tear. During surgery, sometimes a skin graft is necessary to close wounds.

Recommended Treatment & Rehabilitation

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Diagnosis for Dupuytrens contracture is done by looking and feeling your hands. Your doctor will compare your hands to each other and check for puckering on the skin of your palms. He or she will also press on parts of your hands and fingers to check for toughened knots or bands of tissue. Your doctor might also check to see if you can put your hand flat on a tabletop or other flat surface. Not being able to fully flatten your fingers indicates you have Dupuytrens contracture.

In addition, doctors will determine the extent of the condition by applying a grading system. These grade systems are graded from 1 to 3, as described below:

  • Grade 1 – The condition appears as a thick lump, or nodule, and as a band in the muscles of the palm. This band, or stretched line, could evolve or lengthen, as well as cause some pitting of the skin to occur.
  • Grade 2 – This appears as a band surrounding the tendon, impeding the ability to extend the affected finger.
  • Grade 3 – Grade 3 involves the inability to fully straighten the finger.

In the early stages of Dupuytrens contracture, frequent examination and follow-up are recommended. First off, your doctor may want to inject cortisone into the painful nodules. Cortisone can be effective at temporarily reducing pain and inflammation. Heat and stretching treatments by a physiotherapist may also be done to manage pain and to try to slow the progression of the contracture. Your physiotherapist may advise you to wear a splint that keeps the finger straight. This splint is usually only worn during nighttime. The combination of heat, stretching, and a finger splint seems to be the most effective non-surgical treatment for this disease.

Although recovery times among patients vary, you may be advised to attend physiotherapy sessions for a few visits per week for up to six weeks. Afterward, your physiotherapist will instruct you to continue using the splint and perform stretches as a part of a home program for several months.

Stretching does help Dupuytrens contracture, and there are a number of exercises you can do to help manage this condition. Exercises and stretches will not necessarily stop or slow the progression of the contracture, but they are helpful options during the early stages of Dupuytrens contracture. Here are some exercise examples you can try at home:

  • Palm raises – This exercise involves leaving your fingers flat on a surface while raising and lowering only your palm.
  • Finger lifts – To perform this exercise, you can lay your palm flat on a smooth surface, like a table or desk. Next, practice raising each finger one at a time, pausing after each raise for a few seconds. You can repeat this exercise 4-5 times a day.
  • Finger spreads – With your palm on a flat surface, you can also stretch your fingers by spreading them wide and drawing them back in together.
  • Hand press – Firstly, place your hands in a prayer position, then, gently push the palms and fingers of both hands together. Repeat this method 4-5 times a day.
  • Finger bends – This is done by holding your hands in front of you, bending the first two joints of the fingers down, and straightening them.

If the contracture has already begun on any of your fingers, you can use your other hand to push the fingers back into a straight position and hold for a few seconds. You can create an exercise routine and stretch the affected hands multiple times a day.

Unfortunately, despite recovering with the help of these treatments, Dupuytrens contracture is known to progress. Therefore, surgery may be needed at some point to release the contracture and to prevent disability in your hand. Surgery is usually recommended when the joint at the knuckle of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life. When the problem reoccurs or causes severe contractures, surgeons may decide to fuse the individual finger joints together. In worst cases, amputation of the finger may be needed if the contracture restricts the nerves or blood supply to the finger.

Alternative & Homeopathic Treatment

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There are several homeopathic treatments that can help you reduce symptoms without the need for injections and prescription-heavy medications. Some of these alternative treatments for Dupuytren’s contracture include the following:

 

Massage

A massage can be helpful after your hands have dealt with rigorous activity. You can either do this yourself or have a professional massage therapist treat your hand. A gentle massage can delay the progression of the contractures and reduce the risk of them occurring.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Taking NSAIDs, such as ibuprofen or naproxen, can both help reduce swelling and inflammation occurring in your affected hand.

Healthy eating

Most patients who are living with diabetes have a higher risk of developing Dupuytren’s contracture. Therefore, controlling the food you eat along with portion sizes can help your body fight diseases that can facilitate Dupuytren’s contracture.

Reduce pressure

The skin on your palm is where the disease begins, and if you constantly use the affected hand to do various things, it will only worsen. As such, you should do whatever it takes to reduce the pressure in the palm. This may include practicing a looser grip or wearing supportive gloves.