Dupuytren's contracture

Dupuytren's contracture, also known as Dupuytren's disease, causes the fingers to bend inwards (towards the palm). It occurs due to abnormal thickening of connective tissue called fascia within the palm and fingers. These thickened bands of tissue pull the fingers inwards.

Thickening of the fascia usually begins as lumps or nodules in the palm and spreads into the fingers. This most commonly affects the ring finger and little finger, often in both hands.

Dupuytren's contracture is a progressive condition, which means it will continue to get worse. However, the rate at which it worsens varies from person to person, taking months or years.

Dupuytren’s contracture symptoms include:

• Dimples, lumps, pits or ridges on the palm of your hand
• Reduced ability to straighten 1 or more of your fingers due to hard cords that pull your fingers towards your palm
• Reduced ability to lay your hand completely flat, palm down
• Small, hard lumps in your palm, usually near your ring finger or little finger, which may be painful
• Temporary, mild discomfort as new lumps or nodules form
• Thickening of the skin along your palm, as well as other parts of your body eg knuckes and soles of your feet, or in men, the penis

Dupuytren’s contracture causes

The cause of Dupuytren’s contracture is unknown. However, risk factors include:

• A family history of Dupuytren’s contracture
• Being male and/or of Northern European descent
• Being middle-aged or older
• Drinking excessive amounts of alcohol
• Previous hand surgery or hand injuries
• Smoking

Your risk is also higher if you have any of the following health conditions:

• Diabetes
• Epilepsy
• High cholesterol
• Liver disease
• Thyroid disease

Signs of needing treatment for Dupuytren’s contracture

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

Importantly, for most people, the condition does not progress to affecting hand function or causing considerable bending of the fingers towards the palm. In these cases, treatment is not usually needed.

Although Dupuytren's contracture can improve without treatment, in most cases, it worsens without treatment. Your doctor will monitor your condition to check whether your worsening condition reaches the point of needing treatment.

The traditional treatment is surgery, but there are newer treatments for less severe cases, such as injections and radiotherapy.

Surgery is usually only recommended to treat Dupuytren's contracture in 2 situations:

• 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 because this area is harder to treat effectively with surgery over time

Diagnosis and tests for Dupuytren’s contracture

Dupuytren's contracture can usually be diagnosed from a physical examination of your hands and a discussion with your doctor about your symptoms.

Your doctor will consider other potential causes of your symptoms (eg a callus, ganglion or trigger finger) before reaching a diagnosis.

Is Dupuytren’s contracture treatment right for you?

Dupuytren’s contracture can be treated through a minimally invasive procedure or through surgery. The treatment you receive will depend on the progression and state of your contracture.

As every procedure comes with risks, if your condition is not significantly affecting your daily life, you may choose not to have treatment.

Alternative treatments for Dupuytren’s contracture

If surgical treatments are not suitable, there are alternative treatments, including:

• Corticosteroid injections to relieve discomfort caused by contractures
• Physiotherapy to reduce discomfort and tension in your hand
• Radiotherapy to slow the progression of your contractures (when given in the early stages)

There are 5 main procedures to treat Dupuytren’s contracture: 

• Needle fasciotomy
• Open fasciectomy (also known as a palmar fasciectomy)
• Dermofasciectomy
• Radiotherapy
• Collagenese injections

Needle fasciotomy 

This is performed under a local anaesthetic, which means you will be awake but will not feel any pain in the area being treated. It is an outpatient procedure so you can return home on the same day as your procedure.

During a needle fasciotomy, a fine needle is inserted at several points along the thick band of tissue forming your contracture. This loosens the contracture, allowing you to straighten your finger.

It is only suitable if your contracture can be easily seen and your doctor thinks the procedure is likely to be effective over the longer term. It cannot be performed if your contracture is severe or is close to important nerves.

This procedure carries the highest risk of the contracture returning. It also comes with the risk of bleeding, infection and numbness around the site of treatment.

It takes 4–12 weeks to recover from this procedure.

Open fasciectomy

This surgery is performed under a local or general anaesthetic. If you have a general anaesthetic, you will be asleep during your procedure. If you have a local anaesthetic, you will be awake but will not feel any pain.

Several cuts are made along the palm and finger to remove the thickened band of tissue. Of the 3 procedures to treat contractures, this carries the lowest risk of the contracture returning.   

Dermofasciectomy

This surgery is performed under a local or general anaesthetic. Several cuts are made along the palm and finger to remove the thickened band of tissue and the overlying skin. A skin graft is then performed using skin from the forearm.

A dermofasciectomy is usually performed in:

• Contractures that involve the overlying skin
• Individuals who have previously had a fasciectomy
• Individuals who have recurrent Dupuytren’s contractures
• Severe cases of Dupuytren’s contracture in those aged 40 or under

Radiotherapy

This is suitable in earlier stages of the condition and involves exposing your hand to several low doses of radiation. This does not shrink or resolve the contracture but helps slow down the progression of the condition.

It comes with a risk of dry skin after treatment. There is also an extremely low risk of developing cancer in the treated area.

Collagenese injections

In the early stages of the condition, collagenase clostridium histolyticum (CCH) can be injected into the contracture. This causes the thickened tissue to break down.

The day after these injections, you will need to perform straightening and stretching exercises with the support of your doctor. This can cause some mild discomfort.

The injections take a few minutes to administer and are performed as an outpatient procedure. This means you can return home on the same day as your procedure.

Before the procedure

It is important to attend all of your preoperative appointments. Your contractures will be assessed, and you will be asked about your medical history, including any medications you are taking. This will help determine the most suitable treatment.

The risks and benefits of the treatments available will be explained so you can make an informed decision. You will also have an opportunity to ask any questions.

Your care team will explain your options for anaesthesia and what recovery will involve. They will advise you on any support you may need with daily tasks during the first few days of your recovery.

If you decide to have general anaesthesia, your care team will advise you on how long you need to fast immediately before your surgery and whether you need to temporarily stop taking certain medications. It is generally advised that you quit smoking in the run-up to surgery as smoking increases the risk of complications and interferes with healing.

We will also discuss with you whether any further diagnostic tests, such as scans or blood tests, are needed. Any additional costs will be discussed before further tests are carried out.

Who will be involved?

Your care team will involve experienced specialist consultants, specifically an anaesthetist and a hand surgeon. All of our doctors are registered with the UK's General Medical Council.

Your care team will also include expert nurses. All of our nurses are registered with the UK's Nursing and Midwifery Council.

During your recovery, you will also receive care and support from a hand therapist and/or occupational therapist.

The operation

How long does the procedure take?

Procedures for Dupuytren’s contracture can take anywhere from 20 minutes to 2 hours. The length of your procedure depends on the specific procedure and the severity of the contracture. In some cases, usually when a finger has been bent for a long time, an additional surgery called a joint release may be needed.

Anaesthetic choices

A needle fasciotomy is performed under a local anaesthetic. A fasciectomy or dermofasciectomy can be performed under a local or general anaesthetic.

Pain during surgery and after surgery

During surgery, your hand will be numbed with a local anaesthetic, so you will not feel any pain. After surgery, you will be given over-the-counter painkillers, such as paracetamol and/or ibuprofen, to manage your pain. Over several weeks, the pain around your wound site will resolve.

What happens straight after surgery?

If you have a general anaesthetic, you will be taken to a recovery room immediately after your surgery, where you will be closely monitored as it wears off. You will then be taken to a ward where you will continue to be monitored.

If you have a local anaesthetic and are staying overnight in hospital, you will also be taken to a ward for monitoring.  

Your hospital stay

A needle fasciotomy is performed as a day case, so you can return home on the same day as your procedure. If you have a fasciectomy or dermofasciectomy, particularly if you have a general anaesthetic, you may need to stay overnight in hospital.

Recovery time

If you have a needle fasciotomy, it takes around 2 weeks to fully recover. If you have a fasciectomy, it usually takes 2–4 weeks; however, in severe cases of Dupuytren’s contracture, it can take up to 3 months.

As a dermofasciectomy is a more complex operation and is usually performed in more severe cases of Dupuytren’s contracture, complete recovery takes around 3 months.

Short-term side effects

During your recovery, you may experience swelling and stiffness in your fingers and hand, particularly if you have open surgery (a fasciectomy or dermofasciectomy). This will improve over time and with gentle exercises prescribed by your hand therapist.

Swelling usually resolves over several weeks, while stiffness can take longer, particularly in more severe cases.

After the operation

Immediately after your operation, your hand will feel numb. Feeling will return as the effects of the anaesthesia wear off. Local anaesthesia takes several hours to wear off, while general anaesthesia can take up to 24 hours.

As the anaesthesia wears off, you will experience some discomfort and pain; however, this can usually be controlled with over-the-counter painkillers.

It is important to start moving your hand as soon as possible after your procedure. If you have open surgery and have a dressing on your wound site, you can move your fingers within the limits of the dressing.

You should keep your arm elevated above the height of your shoulders to help reduce swelling.

When can you use your hand?

If you have open surgery, it will be several days before you can use your hands to perform light tasks. You should avoid heavier tasks, such as tightly gripping an object or pushing off from a chair, for at least 2 weeks after your procedure.

Wound care

If you have a needle fasciotomy, keep the injection sites dry for 24 hours by wearing a plastic glove or bag over your hand when showering or bathing.

If you have open surgery, keep your wound site dry until the wound has healed and the stitches have been removed. This usually takes 10–14 days.

Pain relief

During your procedure, your hand will be numbed with local anaesthetic. After your procedure, you will be given over-the-counter painkillers. Take these painkillers as instructed by your care team during your recovery.

Sleeping

You may be given a splint to wear while you’re sleeping for several months after your procedure. You should remove the splint when you wake up.

Smoking

Avoid smoking in the run-up to your procedure and during your recovery. Smoking increases the chances of complications and impairs healing.

Driving

If you have a needle fasciotomy, you can return to driving as soon as you can comfortably grip and move the steering wheel.

If you have open surgery, you must wait until your stitches have been removed (usually after 10–14 days) and you can comfortably grip and move the steering wheel.

Time off work

You can return to light work (ie work that does not place a significant strain on your hands) after around 2 weeks. For heavy work, you will need 4–6 weeks off work or, in severe cases of Dupuytren’s contracture, up to 3 months.

When can you return to sports and exercise after surgery?

For sports that need a strong hand grip and/or place a significant strain on your hands, you will need to wait 4–6 weeks or, in severe cases of Dupuytren’s contracture, up to 3 months.

How to improve your recovery

You can improve your recovery through daily exercises prescribed by your hand therapist. This may include:

• Finger joint bends — while supporting the finger, use your other hand to bend and straighten the middle joint

Finger and palm movements:

• Making a closed fist
• Placing the tips of your fingers on the base of your palm ie a flat fist
• Placing the tips of your fingers on the top of your palm ie a hooked position
• Pushing your fingers out so that the joints at the bases of your fingers form a roughly 90° angle
• Opening your hand so that all of your fingers are straight ie in a high-five position

These exercises should be repeated 10 times each.

Every procedure comes with risks. If you have a general anaesthetic, risks include: 

• An allergic reaction
• Breathing problems
• Chest infection
• Damage to your corneas if your eyelids do not fully close during your procedure
• Damage to your teeth when the breathing tube is inserted

Any surgery also comes with the risks of tissue damage, nerve damage, excessive bleeding and infection. You should contact your care team immediately if you notice any of the following signs of infection:

• Excessively warm skin around your wound site
• Green, yellow and/or smelly discharge from your wound site
• Pain or tenderness around your wound site that does not improve or gets worse
• Redness or swelling around the wound site that does not improve or gets worse
• Signs that the wound site is separating

Risks and complications of Dupuytren’s contracture procedures 

Signs of serious complications specific to treatment for Dupuytren’s contracture include discolouration and numbness or tingling of your fingers. If you notice any of these signs, you should contact your care team immediately. 

Treatment can also lead to the following complications: 

• Long-term nerve damage — 2 in every 100 cases for a needle fasciotomy; 3 in every 100 cases for a fasciectomy; and 6 in every 100 cases for a dermofasciectomy
• Long-term swelling and pain in the fingers (complex regional pain syndrome) — 1 in every 100 cases for a needle fasciotomy; 4–10 in every 100 cases for a fasciectomy or dermofasciectomy
• Short-term skin damage or reopening wounds — 4 in every 20 cases for a needle fasciotomy; 1 in every 20 cases for a fasciectomy; and 2 in every 20 cases for a dermofasciectomy