Dupuytren's contracture

Under the skin of the palm lies a firm sheet of connective tissue called the palmar fascia. It anchors the skin so that it does not slide about when the hand grips something. In Dupuytren's contracture the fibres of that sheet gradually thicken and shorten into hard cords that pull a finger down towards the palm. The joint itself is healthy and the tendons are intact: the finger will not straighten because the tightened tissue beneath the skin will not let it. The process moves slowly, over years, and early on it is often noticed by accident.

How it starts

The first thing to appear is usually a small hard nodule at the base of the ring finger or the little finger. It does not move against the skin because it is stuck to it, and that sets it apart from lumps that roll about underneath. Sometimes a dimple shows up beside it, as if the skin had been stitched from within, and the dimple deepens when the hand is straightened out.

A cord then runs from the nodule towards the finger, and it is the cord that bends the finger over time. The ring and little fingers suffer most, the middle finger less often, and the thumb and index finger are barely involved. Both hands are usually affected, though unevenly: on one of them the changes have gone further.

As a rule there is no pain. The nodule may be tender to press early on and then stop being so. What gets in the way is something else: the hand no longer lies flat, the finger catches in a pocket and a sleeve, and washing your face, pulling on a glove or shaking hands becomes awkward. The pace varies enormously from one person to the next; in some it stands still for decades, in others the finger bends within a couple of years.

What else looks like this

Not every lump in the palm is Dupuytren's, and a few things are mistaken for it.

• Ganglion cyst. A soft or springy bump, more often on the wrist or at the base of a finger, mobile and frequently changing size. There is fluid inside it, not scar tissue.
• Trigger finger. The finger jams in a bent position and then straightens with a sudden snap. Here the trouble lies in the tendon and its sheath rather than the fascia, and the treatment is different.
• Callus and hard skin. Thickening of the skin itself from use, with no cord underneath.
• Arthritis of the finger joints. The restriction comes from the joint, with pain and morning stiffness alongside it, and the palm stays soft.

A group of related conditions deserves separate mention. The same scar-like thickening can turn up on the sole of the foot, towards the arch, and on the penis, where it makes the shaft curve during an erection. Firm pads over the backs of the finger joints also occur. All of these are versions of one process, and finding them together is a warning that the course will be more stubborn: an earlier start, both hands more often, and a greater chance of it coming back after surgery. Tell the doctor if any of this is present.

Why the tissue thickens

What sets it off is not known. What is known is that cells in the fascia start behaving like cells in a healing wound and lay down surplus collagen where nobody has made a wound at all. The people who fall into this group are:

• those with relatives who had the same thing, since heredity carries the most weight here;
• men, in whom it appears markedly more often and runs a heavier course;
• people past fifty, although it can begin earlier;
• people of northern European descent;
• people with diabetes;
• people with epilepsy and those taking anticonvulsant medicines;
• smokers and people who drink heavily on a regular basis.

Manual work on its own does not cause the contracture, contrary to a widely held belief. The part played by years of using vibrating tools is debated, but that link is weaker than heredity. An injury to the hand does sometimes seem to nudge the process along in someone already predisposed.

There is nothing that prevents it: no method has been shown to do so. Nor can a return after treatment be ruled out with any certainty.

The table test and when to see a doctor

There is a simple check to do at home. Rest your palm on a table and try to press the whole of it, fingers included, flat against the surface. If a gap remains between the table and a finger and the hand will not lie flat, that is the threshold beyond which it is worth being seen.

It is worth making an appointment if:

• a finger has bent so far that the palm no longer rests on the table;
• ordinary tasks have become difficult: washing your face, putting on a glove, picking up something large;
• the finger catches on clothing and you injure yourself on it;
• the lump is growing quickly or has turned painful;
• the skin over it is red, hot or discharging, which points to infection rather than contracture.

There is one reason not to let it drift: the further the finger has bent, the poorer the result of any procedure. This applies above all to the middle joint of the finger, whose contracture straightens far less well than one sitting at the base, because after long enough in flexion the joint capsule shortens too. Early nodules, by contrast, are left alone: while the hand still works there is no reason to intervene.

What is done when the hand stops coping

Treatment is aimed not at the disease but at its consequence: it releases the tension and gives extension back. No method cures it in the sense of stopping the tissue thickening ever again. A hand specialist will explain what suits your case and is obliged to name the risks as well as the gain.

• Needle fasciotomy. The cord is punctured with a needle at several points until it divides, and the finger is straightened. It is done under local anaesthetic, you go home the same day, and normal activity resumes in about two weeks. The price of that simplicity is that the cord returns more often than after surgery.
• Partial fasciectomy. Through an incision in the palm and finger the altered tissue is removed. A general anaesthetic or a nerve block for the whole arm is used; discharge is usually the same day and recovery takes one to three months. It has the lowest rate of return, which is why it is regarded as the mainstay.
• Dermofasciectomy. The same removal, but taking the overlying skin with it, and the gap is closed with a skin graft from elsewhere. It is kept for stubborn and repeated cases: recovery is longer, but it comes back less.
• Enzyme injection. In some countries the cord is dissolved by an enzyme injected into it, and a day or two later the finger is straightened with no incision at all. Availability differs between countries, so it is worth asking about specifically.

The risks are similar across all the options and should be known in advance: bleeding, infection, damage to the digital nerve running alongside with lasting numbness, damage to a blood vessel, tearing of the skin, stiffness. Rarely a prolonged pain syndrome develops with swelling and stiffness of the whole hand; it is a serious state of affairs, and that is precisely why people are warned about it.

Splints, massage and stretching the finger do not halt the process. As a way of buying time they simply do not work, and relying on them while putting off a consultation is a mistake.

After the procedure

The hand does not recover all at once. The first days go on controlling swelling and keeping the hand raised, after which hand therapy takes over: exercises for extension and flexion, work on the scar, and sometimes a night splint holding the finger in the position gained. These sessions matter more than the operation itself, because without them the finger draws back in.

Honest expectations look like this. The finger may not straighten completely, particularly if it had been sharply bent for a long time. Grip strength returns gradually, over months. The scar is firm and sensitive at first and softens later. The skin of the finger stays numb for a while. And most importantly, the cord may reappear some years on. That does not mean the operation failed; it is how the condition behaves.

Contact a doctor straight away if, after the procedure, pain is increasing, a fever has started, redness is spreading beyond the wound, there is discharge from it, the finger has turned pale or cold, or numbness is growing rather than settling.

What is in your hands

Heredity cannot be argued with, but some things can be done.

• Stop smoking and cut down on alcohol. Both are linked with a heavier course, and both pay off well beyond the hand.
• Keep diabetes under control if you have it.
• Wear gloves and take breaks when working with vibrating tools.
• Adapt your grip: thick handles on tools and cutlery, loops instead of small fastenings. This removes much of the inconvenience without any treatment at all.
• Do not wait until the finger is pressed against the palm. Testing the hand against a table every few months is easier than winning extension back afterwards.

Online consultation

Remotely it is straightforward to work out what is actually in the palm: from a description and a photograph a doctor will tell a Dupuytren's nodule from a cyst, a callus or a trigger finger, and say whether an examination in person is needed. We can go over which stage you are at and whether it is time for a hand specialist; compare the procedures and their recovery times; discuss how all this ties in with your diabetes or your anticonvulsant treatment; and set out the exercise plan after surgery, explaining what counts as normal healing and what does not. Signs of infection or of deterioration after an operation are not assessed remotely: with those you see a doctor in person and without delay.

This material is for information only and does not replace medical advice.