Dupuytren's Contracture

Dupuytren's contracture is a slow build-up of scar-like tissue in the palm of your hand. The thin layer of fibrous tissue under the skin, the palmar fascia, gradually forms small lumps (nodules), then thick rope-like cords, that pull one or more fingers, most often the ring and little finger, into a permanently bent position. The exact cause is unknown, but genes play a big role: it is especially common in men of Northern European descent over age 50.

It is usually painless. The real problem is the gradual loss of being able to flatten your hand, which gets in the way of wearing gloves, shaking hands, washing your face, or reaching into pockets. Both hands are affected in about half of patients, and the condition often runs in families.

The earliest sign is usually a firm nodule, a small, painless lump, in the palm near the base of your ring or little finger. Over months to years, a thick cord develops under the skin that you can see and feel running from the palm toward the finger. The finger gradually curls into a bent position that you cannot straighten on your own.

The contracture is usually painless, which is why many people wait years before seeking treatment. The real problem is functional: you cannot flatten your hand on a table, wearing gloves becomes difficult, and reaching into pockets or washing your face feels awkward.

The diagnosis is made by exam alone: nodules and cords are easy to feel and see in the palm. Your surgeon will use the tabletop test (placing your palm flat on a table) to gauge how much you can no longer flatten the hand, and check how far each finger joint will bend. No imaging is needed. The bend at the middle finger joint matters most: it gets harder to fully straighten the longer it has been bent.

Treatment is guided by how much the contracture is getting in the way of daily life, not by the cords alone. The options below are the ones we can do in the office, and they are usually where we start before considering an operation.

1. Observation

   Mild Dupuytren's that is not getting in the way of daily activities is simply watched. It does not always progress, and it is reasonable to wait until function is affected before treating.

2. Collagenase Injection (Xiaflex)

   An FDA-approved enzyme injection (Xiaflex) that dissolves the cord chemically; the next day, your surgeon manipulates the finger to break the weakened cord. It is done in the office, with no operating room. It works best for cords pulling on the knuckle joint, where the finger meets the palm, and is less reliable for cords pulling on the middle finger joint.

3. Needle Aponeurotomy

   Your surgeon uses a needle through the skin to weaken and break the cord in the office. Recovery is quick and the cost is lower, but the cord is more likely to re-form over the years than after surgery.

Surgery is considered once the knuckle joint can no longer straighten enough to lay the hand flat (roughly when the tabletop test fails), or when any bend develops at the middle finger joint, which becomes harder to fully straighten the longer it stays bent.

The operation, an open fasciectomy, removes the diseased cord and nodules through an incision in the palm so the finger can straighten. Compared with the in-office options, it has a longer recovery and is followed by hand therapy and a period of night splinting, but it gives the most complete correction and the lowest chance the contracture comes back.

External patient-education references and related OSI pages for additional background:

• AAOS OrthoInfo, patient education library
• OSI glossary, orthopedic terminology in plain language