Dupuytren's contracture

Nodules and long cords form beneath the skin in your hand. These are hard and inflexible, similar to scar tissue, so you can’t straighten one or more fingers. It usually affects the ring and little fingers and can affect both hands at the same time. 

Eventually, your fingers bend towards the palm of your hand — this is called a contracture and can limit what you can do at home and work. Not everyone with this condition will develop contractures, which is why it is sometimes called Dupuytren’s disease. 

Dupuytren's contracture is a common condition affecting around one in 20 people in the UK. It’s six times more common in men than women and more common in older people.

There is no cure but it can be treated.

Your doctor may offer you an injection to weaken the tissue that's keeping your fingers bent, or they can be surgically straightened.

Left untreated it tends to get worse over months or years, but only a small number of people need surgery.

Symptoms include:

• A lump or nodule on the palm of your hand(s), usually near the ring or little fingers, which may be painful — this is usually how the condition starts
• Hard cords in your palms that appear to grow from a nodule and pull your fingers towards your palm — this is not usually painful but at this stage, you may start to have difficulty using your hand, starting with your ring finger, then little finger and middle finger
• Skin texture changes with small pits in the palm(s)
• Thickened tissue under your skin in other parts of your body — eg your knuckles, penis or soles of your feet

Contractures (bending of the fingers towards the palm) can vary in severity and usually affect both hands. 

If your fingers are bent and you can't lay your hand down flat or find daily tasks using your hands difficult, you should see your GP. 

Your GP should be able to give you an accurate diagnosis after asking you some questions and a careful examination of both hands.

No other tests or investigations are likely to be necessary. Your GP will consider other possible causes of your problem, such as a callus, ganglion or trigger finger.

The exact cause of Dupuytren's contracture is still unknown, but it's been linked to:

• A family history of the condition
• Being of northern European descent
• Diabetes or epilepsy
• Injury or surgery to the hand or wrist — especially in someone who has a family history of the condition
• Lifestyle factors — drinking a lot of alcohol, smoking and using vibrating hand tools 

However, most people with Dupuytren's contracture do not have any of these risk factors. It is not yet known whether this condition can be prevented or stopped from returning. 

In the early stages of the disease, treatment usually can’t help. If you're treated, you'll often need treatment again sometime later. Treatment is therefore usually only recommended if your fingers have started bending towards your palm and/or your hand function is affected. 

For most people, the condition does not progress to affecting hand function or causing considerable bending of the fingers towards the palm. Dupuytren's contracture may improve without treatment but in most cases, it worsens without treatment. Your doctor can monitor your condition to review whether you need treatment. 

Traditional treatment is surgery but there are newer treatments for less severe cases, such as injections and radiotherapy. Surgery is usually only recommended if: 

• One of your knuckle joints is stuck at an angle of 30–40° or more
• Part of one of your fingers is bent towards your palm between its small joints by 10–20° — surgery may be recommended sooner if the bend affects the first joint of your finger as this area is harder to treat effectively with surgery over time

The main treatment options are:

• Collagenase clostridium histolyticum injections into the thickened tissue — these injections, which take a few minutes to administer as an outpatient procedure, break down the thickened tissue and the next day are followed by straightening and stretching of the fingers by a doctor, which can cause some discomfort
  
  
• Fasciotomy — this is carried out under general or local anaesthetic and comes with the risks of bleeding, infection and numbness; it involves: 
• a surgeon making a cut along your palm and finger to straighten it — you can return home the same day you have surgery
• finger splinting and physiotherapy after your surgery
• a recovery period of 4–12 weeks
  
  
• Open fasciectomy — unlike a fasciotomy where the thickened tissue is cut, a fasciectomy involves more extensive surgery to remove the thickened tissue and is the most effective procedure to reduce the risk of Dupuytren's contracture returning, though the risk remains high 
  
  
• Needle fasciotomy — performed as an outpatient procedure under local anaesthetic but is less effective than surgery in preventing the return of Dupuytren's contracture and comes with the risks of a cut opening up in your skin, numbness and pain; it involves:
• a doctor inserting a needle into several places along your affected finger and palm to loosen and straighten it — you can return home the same day you have surgery
• a recovery period of up to two weeks
  
  
• Radiotherapy — in the early stages of the condition, your affected hand is exposed to several low doses of radiation to slow the progression of the condition, however, some people develop dry skin after treatment and there is the very unlikely risk of developing cancer in the treated area

A needle fasciotomy may not be suitable if: 

• The procedure is likely to be ineffective in the long term — over half of contractures return 3–5 years after a needle fasciotomy but the procedure can, in some cases, be repeated
• Your contracture is close to important nerves in your hand
• Your contracture is severe
• Your doctor can't see the end of the needle after it's inserted — this increases the risk of damage to nearby blood vessels, nerves and tendons, and therefore long-term problems after the procedure

A needle fasciotomy is more often recommended to older people who aren't suitable for more extensive surgery. 

As with all surgery, there are risks and possible complications, such as your finger being less flexible, not fully straight or weaker after surgery. Your consultant will carefully explain these. Your contracture may also return a few years after treatment. 

Depending on your treatment, your aftercare and recovery will vary. You may need to wear a cast or splint on your hand for a few days and wear a splint when sleeping for 3–6 months. You may also have bruising, pain, stiffness and swelling for a few weeks. Your doctor may recommend doing hand exercises for up to six months and/or may refer you to a physiotherapist. 

In most cases, you can start using your hand after a few days but it may be several weeks before you can resume all of your usual activities.