Under the palmar skin there is a connective tissue layer called palmar aponeurosis, which serves to anchor the skin. In Dupuytren's contracture, a knotty and/or stringy, cord-like thickening of this layer develops as a result of an increase in the number of connective tissue cells (myofibroblasts). The cords can extend over the entire palm up to the finger joints and over time they may slowly contract. This leads to a flexion contracture of the affected fingers and prevents their full extension.
These changes do not regress spontaneously. The little finger is most often involved, followed by the ring finger and the thumb. The disorder often appears bilaterally and usually between the age of 40 and 60. Men are affected significantly more than women.
The exact cause of this benign disease is unknown. Familial occurrence is observed and there is an association with diabetes.
In general patients themselves note the knots and cords in their palm, that are typically painless. However, increasing inability to extend the fingers is experienced as annoying in everyday life. This is the most common reason for medical consultation. Usually the disorder progresses slowly, but there are cases where the course is more aggressive. This primarily occurs in younger patients (under forty years old) with bilateral manifestation, and similar changes on the feet (Ledderhose disease or plantar fibromatosis), and a familial component.
The goal of treatment is to correct the flexed malposition of the fingers and thus to improve hand function. This requires transection of the cords that cause digital flexion. If they are superficial and palpable under the skin, one may be able to cut them through the skin (percutaneously) with the aid of needles (needle fasciotomy). Also available is therapy with a new medication, which is injected into the fibrous cord and dissolves it at the site of infiltration.
If the cords are not easily palpable, they must be surgically excised through larger incisions in the palm. In severe cases, often the contracted joint capsules of the digital joints needs to be released. Sometimes a small skin graft or a local skin flap is necessary to close the affected site completely.
When should one operate?
Surgery is usually recommended when the patient is no longer able to extend his hand onto a flat surface. If treatment is deferred for too long it may no longer be possible to achieve full finger extension. Isolated knots without flexion contracture of the fingers, however, should only be treated surgically when they produce actual discomfort, because postoperative scar formation can lead to further problems. Since reccurence rates even with radical operations are relatively high, surgery should not be performed too soon.
Follow up care
To achieve the best possible outcome systematic follow up care is needed. This consists of wearing a night splint for a period of three to six months. Depending on the findings, a daytime splint may also be applied for the first two to six weeks. During hand therapy, the patient is taught regular exercises and is instructed in the care of the scar.
Full strength can be recovered after wound healing is complete, which takes about two to four weeks.