Introduction

Dupuytren's contracture, a common disorder of the fingers causing patients to lose the ability to extend their fingers. The disorder may occur suddenly, but more commonly, progresses slowly over a period of years. The disease usually doesn't cause symptoms until after the age of forty.

Lying just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand holding them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers.

Dupuytren's contracture forms when the palmar fascia tightens, causing the fingers to bend.

The condition first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. Nodules form and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren's contracture usually affects only the ring and little finger.

Causes

No one knows exactly what causes Dupuytren's contracture. The condition is rare in young people but becomes more common with age. When it appears at an early age, it usually progresses rapidly and is often very severe. The condition tends to progress more quickly in men than in women.

People who smoke have a greater risk of having Dupuytren's contracture. Heavy smokers who abuse alcohol are even more at risk. Recently, scientists have found a connection with the disease among people who have diabetes. It has not been determined whether or not work tasks can put a person at risk or speed the progression of the disease.

Symptoms

Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. We lose this control as the disorder develops and the palmar fascia contracts, or tightens. This contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

Without treatment, the contracture can become so severe the finger cannot be  straightened, and eventually you may not be able to effectively use your hand. Because our fingers are slightly bent when the hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually seek medical advice for cosmetic reasons or the loss of use of their hand. At times, the nodules can be very painful. For this reason many patients are worried that something very serious is wrong with their hand.

Diagnosis

The doctor will review the history of your problem and examine your hand and finger. Usually, special tests are unnecessary. Abnormal fascia will thicken and can have cords or nodules that feel like small knots or thick bands under the skin and along the fascia. These nodules usually form first in the palm of the hand. As the disorder progresses, nodules form along the finger. These nodules can be felt through the skin, and you may have felt them yourself. Depending on the stage of the disorder, your finger may have started to contract, or bend.

The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten out completely. This is considered zero degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected finger. The loss of ability to straighten out your finger is measured in degrees. 

Measurements taken at later follow-up visits will tell how well treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years, and then suddenly nodules will begin to grow and their finger will begin to contract.

Treatment 

Conservative Treatment

In the early stages of this disorder, frequent examination and follow-up is recommended. The doctor may inject painful nodules with cortisone. Cortisone can be effective at temporarily easing pain and inflammation. Heat and stretching treatments given by a physical or occupational therapist may also be prescribed for pain control and to slow the progression of the contracture. Treatment may also consist of wearing a splint that keeps the finger straight. 
 
The nodules of Dupuytren's contracture are almost always limited to the hand. However, Dupuytren's contracture is known to progress, so surgery may be needed at some point to release the contracture and to prevent disability in your hand.

Surgery

Surgery is usually recommended when the joint at the knuckle of the finger reaches thirty degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life.

Surgery for the main knuckle of the finger (at the base of the finger) has better long-term results than when the middle finger joint is tight. Tightness is more likely to return after surgery for the middle joint.

The goal of surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. If the problem is not severe, it may be possible to free the contracture simply by cutting the cord under the skin. If the palmar fascia is more involved and more than one finger is bent, the surgeon may take out the whole sheet of fascia.

The success of treatment by removal of the entire palmar fascia depends a great deal on completing physical or occupational therapy as prescribed. Ill effects from removing the entire palmar fascia are minimal, although the fingers may bend backward slightly more than normal. If you decide to have surgery, you must commit to doing the therapy needed to make surgery as successful as possible.

Rehabilitation

Conservative treatments to slow or reverse the contracture include heat treatments, stretching, and finger splints. These treatments may be directed by a physical or occupational therapist. Sessions may be scheduled for a few visits per week for up to six weeks. After that, you'll continue to use the splint and do the stretches as part of a home program for several months afterward.

After surgery, your hand will be bandaged with a well-padded dressing and a splint for support. Physical or occupational therapy sessions may be needed after surgery for up to six weeks. Visits will include heat treatments, soft tissue massage, and vigorous stretching.