Dupuytren's Contracture: Causes, Symptoms & Treatment Options

What Is Dupuytren's Contracture?

Dupuytren's contracture is a hand deformity caused by abnormal thickening and tightening of the palmar fascia, the layer of connective tissue beneath the skin of the palm. This causes one or more fingers to bend toward the palm and become difficult or impossible to straighten. The condition is named after Baron Guillaume Dupuytren, the French surgeon who first described the surgical treatment in 1831.

The palmar fascia is a triangular sheet of fibrous tissue that lies just beneath the skin of the palm. In healthy individuals, this tissue provides structural support and protection for the underlying tendons, nerves, and blood vessels. In Dupuytren's contracture, this normally flexible tissue undergoes a pathological transformation where the collagen fibers become disorganized and contract, forming thick cords and nodules.

The disease process begins with the formation of small, firm nodules in the palm, typically near the base of the ring finger or little finger. These nodules are composed of abnormal myofibroblasts, specialized cells that produce excessive amounts of collagen. Over time, these nodules may develop into rope-like cords that extend from the palm into the fingers. As these cords contract, they gradually pull the affected fingers into a flexed position.

Dupuytren's contracture is also commonly known as "Viking disease" or "Celtic hand" because of its particularly high prevalence among populations of Northern European descent, especially those with Scandinavian, Scottish, or Irish ancestry. Historical evidence suggests the condition may have spread across Europe following Viking migration patterns, which explains its geographic distribution pattern.

The condition typically affects both hands in approximately 50% of cases, though usually with different degrees of severity. When both hands are involved, this bilateral presentation often indicates a more aggressive disease course with higher likelihood of recurrence after treatment.

Who Gets Dupuytren's Contracture?

Dupuytren's contracture shows a distinct demographic pattern that helps identify those at highest risk. The condition is significantly more common in men than women, with a male-to-female ratio of approximately 3-4:1. However, when women develop the disease, they tend to have milder forms that progress more slowly.

Age is one of the strongest risk factors. While Dupuytren's contracture can occur at any age, it rarely appears before age 40 and becomes increasingly common with advancing age. Population studies show prevalence rates of approximately 3-6% in the general Western population, rising to 20-30% in men over 60 years of age in Northern European countries.

Certain medical conditions significantly increase the risk of developing Dupuytren's contracture. People with diabetes mellitus have a 3-4 times higher risk compared to non-diabetic individuals. Other associated conditions include epilepsy, liver disease, and alcoholism, though the exact mechanisms linking these conditions to Dupuytren's are not fully understood.

What Are the Symptoms of Dupuytren's Contracture?

The main symptoms of Dupuytren's contracture include painless nodules or lumps in the palm, visible cords or bands under the skin extending toward the fingers, and progressive inability to straighten one or more fingers. The ring finger and little finger are most commonly affected. Unlike many hand conditions, Dupuytren's contracture is typically not painful.

Dupuytren's contracture develops gradually over many years, and the progression of symptoms follows a predictable pattern. Understanding these stages can help identify the condition early and determine when treatment may be beneficial. The disease progression can be divided into three main phases: the proliferative phase, the involutional phase, and the residual phase.

In the early proliferative phase, the first noticeable sign is usually the appearance of small, firm nodules in the palm of the hand. These nodules typically develop near the base of the ring finger or little finger, at the level of the distal palmar crease (the crease closest to the fingers). The nodules may feel slightly tender when pressed, particularly in the early stages, but significant pain is uncommon. The overlying skin may appear puckered or dimpled due to attachment of the diseased tissue to the dermis.

During the involutional phase, the nodules begin to mature and may coalesce to form cord-like structures that extend from the palm into the fingers. These cords represent bands of contracted fascia that gradually shorten over time. As the cords contract, they begin to pull the affected fingers into flexion, first at the metacarpophalangeal (MCP) joint where the finger meets the palm, and later at the proximal interphalangeal (PIP) joint in the middle of the finger.

The residual phase represents the final stage where active tissue changes have largely ceased, leaving behind established contractures. At this stage, the fingers may be significantly bent toward the palm, and the skin may become tethered and difficult to move independently over the underlying cords.

Stages of Finger Contracture

The severity of Dupuytren's contracture is typically measured by the degree of flexion contracture at each joint. Several classification systems exist, but the most commonly used is based on the total passive extension deficit (the amount that the finger cannot be straightened).

Which Fingers Are Most Commonly Affected?

Dupuytren's contracture shows a distinctive pattern of finger involvement. The ring finger (fourth digit) is most frequently affected, followed by the little finger (fifth digit). Together, these two fingers account for approximately 75% of all cases. The middle finger is involved less commonly, and the index finger and thumb are rarely affected.

This pattern of involvement relates to the anatomy of the palmar fascia, which has its strongest attachments and thickest bands extending toward the ulnar side of the hand (the side of the little finger). The pretendinous bands of the palmar fascia that connect to the ring and little fingers are anatomically predisposed to develop the pathological changes characteristic of Dupuytren's disease.

Symptoms That Are NOT Typical of Dupuytren's

It is important to recognize that certain symptoms are not characteristic of Dupuytren's contracture and may indicate a different condition requiring alternative diagnosis and treatment:

• Significant pain: While early nodules may be mildly tender, substantial pain is unusual and should prompt evaluation for other conditions
• Numbness or tingling: Dupuytren's contracture does not typically cause nerve compression symptoms
• Weakness: Hand strength is usually preserved; weakness suggests nerve or tendon problems
• Rapid onset: Symptoms developing over weeks rather than months or years are atypical
• Swelling of the entire hand: Localized nodules and cords are characteristic, not diffuse swelling

What Causes Dupuytren's Contracture?

The exact cause of Dupuytren's contracture is unknown, but it results from abnormal collagen production in the palmar fascia. Genetic factors play a major role, with family history being the strongest risk factor. Other contributing factors include Northern European ancestry, diabetes, smoking, heavy alcohol consumption, and possibly manual labor, though no single cause has been definitively identified.

The pathophysiology of Dupuytren's contracture involves a complex interplay of genetic predisposition, cellular abnormalities, and environmental factors. At the cellular level, the disease is characterized by the proliferation and activation of myofibroblasts, specialized cells that combine features of fibroblasts and smooth muscle cells. These cells produce excessive amounts of type III collagen and other extracellular matrix components while simultaneously contracting, leading to tissue shortening.

Research has identified several genes associated with increased susceptibility to Dupuytren's disease. These genetic variants affect various cellular pathways including Wnt signaling, which plays a crucial role in wound healing and fibrosis. The strong hereditary component is evidenced by the observation that approximately 60-70% of patients have a family history of the condition, and first-degree relatives of affected individuals have a 3-fold increased risk of developing the disease.

While genetics provides the underlying susceptibility, various environmental and health factors appear to influence disease expression and progression. Understanding these risk factors can help identify individuals who may benefit from early monitoring and intervention.

Risk Factors for Dupuytren's Contracture

Several factors have been consistently associated with increased risk of developing Dupuytren's contracture:

• Northern European ancestry: Highest prevalence in Scandinavian countries, Scotland, Ireland, and among their descendants worldwide
• Family history: Having a first-degree relative with Dupuytren's increases risk 3-fold; the condition follows an autosomal dominant inheritance pattern with variable penetrance
• Male sex: Men are affected 3-4 times more frequently than women
• Age over 50: Risk increases significantly with age; rare before age 40
• Diabetes mellitus: 3-4 times higher risk; diabetic patients may develop more aggressive disease
• Smoking: Current and former smokers have increased risk, possibly due to effects on microvascular circulation
• Heavy alcohol consumption: Particularly associated with liver disease, though the relationship is complex
• Epilepsy: Higher prevalence in epileptic patients, possibly related to certain anticonvulsant medications

The role of manual labor and hand trauma in causing Dupuytren's contracture remains controversial. While some studies have suggested an association with heavy manual work or repetitive hand use, the evidence is inconsistent. It appears more likely that physical trauma may accelerate disease progression in genetically predisposed individuals rather than directly causing the condition.

Related Conditions: Dupuytren's Diathesis

Some patients exhibit features of Dupuytren's diathesis, a more aggressive form of the disease characterized by earlier onset (before age 50), bilateral hand involvement, positive family history, and the presence of similar fibromatosis in other body sites. These related conditions include:

• Ledderhose disease: Fibromatosis of the plantar fascia (sole of the foot)
• Peyronie's disease: Fibromatosis of the tunica albuginea of the penis
• Garrod's pads: Thickening over the dorsal aspect of the finger joints (knuckle pads)

Patients with Dupuytren's diathesis tend to have more aggressive disease progression and higher recurrence rates following treatment, making careful surgical planning and patient counseling particularly important in this group.

How Is Dupuytren's Contracture Diagnosed?

Dupuytren's contracture is diagnosed through physical examination alone in most cases. The doctor examines the palm for nodules and cords, measures finger range of motion, and performs the "tabletop test" to assess contracture severity. Imaging studies are rarely needed. If you cannot place your palm flat on a table because one or more fingers remain bent, this indicates significant contracture that may benefit from treatment.

The diagnosis of Dupuytren's contracture is primarily clinical, based on the characteristic findings of nodules, cords, and contracture in typical locations. A detailed history helps identify risk factors and disease progression, while careful physical examination confirms the diagnosis and assesses severity. In the vast majority of cases, no laboratory tests or imaging studies are necessary.

During the clinical examination, the physician will inspect both hands, noting any visible nodules, cords, or skin changes in the palm. Palpation reveals the characteristic firm, immobile nodules that are adherent to the overlying skin but separate from the underlying flexor tendons. Unlike tendon problems where the mass moves with finger flexion and extension, Dupuytren's nodules remain stationary regardless of finger position.

The Tabletop Test (Hueston's Test)

The tabletop test is a simple, practical assessment that helps determine when treatment may be beneficial. To perform this test:

1. Find a flat, hard surface such as a table or desk
2. Attempt to place your entire palm flat against the surface with all fingers extended
3. Note whether you can achieve complete contact between the palm and surface

If you cannot place your palm completely flat because one or more fingers remain bent, this is considered a positive tabletop test. A positive test traditionally indicates that treatment may be beneficial and is often used as a threshold for considering intervention. However, treatment decisions also depend on the patient's functional limitations and personal preferences.

Measuring Contracture Severity

Contracture severity is measured using a goniometer, a device that measures joint angles. The examiner measures the passive extension deficit at each affected joint - that is, how many degrees short of full extension the finger reaches when the examiner attempts to straighten it. The total extension deficit is the sum of contractures at all affected joints.

For example, if the MCP joint has a 30-degree contracture and the PIP joint has a 20-degree contracture, the total extension deficit for that finger is 50 degrees. This measurement helps track disease progression and evaluate treatment outcomes.

When Is Imaging Needed?

Imaging studies are rarely necessary for diagnosing Dupuytren's contracture. However, certain situations may warrant additional evaluation:

• Atypical presentation: When features suggest a different diagnosis, such as a tumor or tenosynovitis
• Preoperative planning: Ultrasound may help delineate cord anatomy in complex cases
• Recurrent disease: To assess the extent of recurrence and plan revision surgery

Ultrasound can visualize the hypoechoic (dark-appearing) cords of Dupuytren's tissue and may help distinguish it from other masses. MRI provides excellent soft tissue detail but is seldom needed and is not cost-effective for routine diagnosis.

When Should You See a Doctor for Dupuytren's Contracture?

Consult a healthcare provider if you notice nodules in your palm, have difficulty straightening your fingers, or if the condition interferes with daily activities like gripping objects, shaking hands, or wearing gloves. A positive tabletop test (inability to place your palm flat on a table) or contracture exceeding 30 degrees at any joint typically indicates that treatment evaluation is appropriate.

The decision of when to seek medical evaluation for Dupuytren's contracture depends on several factors including the rate of progression, functional impairment, and personal concerns. Because the condition progresses slowly in most cases, immediate evaluation is rarely necessary, but early assessment can help establish a baseline and inform the timing of future treatment.

Many people with early Dupuytren's contracture - characterized by nodules only, without significant contracture - may choose to monitor their condition without immediate treatment. During this observation period, periodic self-assessment using the tabletop test can help identify when professional evaluation becomes appropriate.

Signs That Evaluation Is Recommended

You should consider consulting a healthcare provider specializing in hand conditions if you experience:

• A positive tabletop test - you cannot place your palm flat on a table
• Contracture of 30 degrees or more at any joint
• Difficulty with specific functional tasks such as:
  • Putting your hand in your pocket
  • Wearing gloves
  • Shaking hands comfortably
  • Gripping large objects
  • Placing your hand flat for activities like typing or playing piano
  • Washing your face
• Rapid progression of contracture
• Concerns about cosmetic appearance

For individuals with risk factors for aggressive disease (young age at onset, family history, bilateral involvement, or related fibromatosis at other body sites), earlier evaluation may be appropriate even with milder contracture, as these patients may benefit from closer monitoring and earlier intervention.

How Is Dupuytren's Contracture Treated?

Treatment options for Dupuytren's contracture include needle fasciotomy (minimally invasive needle procedure), collagenase injection (enzyme that dissolves the cord), and surgical fasciectomy (removal of diseased tissue). Choice of treatment depends on disease severity, patient factors, and surgeon expertise. No treatment permanently cures the condition; recurrence rates range from 20-65% depending on the method used.

The management of Dupuytren's contracture has evolved significantly over the past several decades, with multiple effective treatment options now available. The fundamental goal of all treatments is to release the contracted cords and restore finger extension. However, because Dupuytren's is a disease of the tissue itself rather than a structural problem that can be permanently fixed, recurrence is possible with all treatment methods.

The choice of treatment depends on multiple factors including the severity and location of contracture, patient age and health status, functional demands, previous treatments, and surgeon expertise. A shared decision-making approach, where the patient and surgeon discuss the benefits, risks, and expected outcomes of each option, leads to the best results.

Observation (Watchful Waiting)

For patients with early disease - nodules only or minimal contracture that does not affect function - observation may be the most appropriate initial approach. Dupuytren's contracture progresses slowly in most cases, and treatment of asymptomatic disease provides no proven benefit while exposing patients to potential risks and costs.

During observation, patients should perform regular self-assessment using the tabletop test and monitor for functional limitations. If contracture progresses to the point where the tabletop test becomes positive or activities become limited, reevaluation for active treatment is appropriate.

Needle Fasciotomy (Percutaneous Needle Aponeurotomy)

Needle fasciotomy is a minimally invasive procedure performed in the clinic setting under local anesthesia. The surgeon uses a hypodermic needle to perforate and weaken the contracted cord at multiple points. The finger is then gently extended, causing the weakened cord to rupture and release the contracture.

This procedure has several advantages: it is quick (typically 15-30 minutes), performed as an outpatient, allows rapid recovery, and can be repeated if recurrence occurs. Most patients can return to light activities within a few days. The main disadvantages are higher recurrence rates compared to surgery (approximately 50-65% at 5 years) and limitations in treating severe or complex contractures.

Needle fasciotomy is particularly well-suited for:

• Older patients who wish to avoid surgery
• Patients with significant medical comorbidities
• MCP joint contractures (better results than PIP joint contractures)
• Patients who prefer a minimally invasive approach and accept the higher recurrence risk

Collagenase Injection (Xiaflex)

Collagenase clostridium histolyticum (brand name Xiaflex) is an injectable enzyme that breaks down the collagen in Dupuytren's cords. The treatment involves two visits: the first for injection of the enzyme into the cord, and the second (typically 24-72 hours later) for finger manipulation to rupture the enzymatically weakened cord.

Collagenase injection offers a middle ground between needle fasciotomy and surgery in terms of invasiveness and outcomes. Success rates are similar to needle fasciotomy, with approximately 65-90% of treated joints achieving less than 5 degrees of residual contracture immediately after treatment. However, recurrence rates are also similar to needle fasciotomy at approximately 50-60% at 5 years.

Notable considerations with collagenase injection include:

• Significant bruising and swelling are common after treatment
• Skin tears may occur during manipulation
• Multiple injections may be needed for multiple affected digits
• Cost may be higher than other options in some healthcare systems
• Availability varies by country (not available in all markets)

Surgical Treatment

Surgical fasciectomy involves excision of the diseased palmar fascia through an incision in the palm and/or finger. This remains the most definitive treatment for Dupuytren's contracture, offering the lowest recurrence rates (approximately 20-40% at 5 years for limited fasciectomy). Several surgical approaches exist:

Limited (selective) fasciectomy is the most commonly performed procedure. The surgeon removes only the diseased fascia while preserving normal tissue. This approach balances thorough disease removal with minimizing surgical trauma and complications. Recovery typically takes 4-6 weeks before returning to normal activities.

Dermofasciectomy involves removing the diseased fascia along with the overlying skin, which is then replaced with a skin graft. This more extensive procedure is reserved for recurrent disease or aggressive presentations, as the skin graft appears to reduce recurrence rates in the grafted area.

Surgical treatment may be recommended for:

• Severe contracture (greater than 60 degrees total)
• PIP joint contracture (lower success rates with non-surgical methods)
• Recurrence after previous non-surgical treatment
• Younger patients with aggressive disease (may benefit from more durable correction)
• Multiple digit involvement requiring comprehensive treatment

Post-Treatment Rehabilitation

Regardless of the treatment method chosen, post-treatment care is essential for optimal outcomes. Hand therapy and rehabilitation help maintain the correction achieved, prevent stiffness, and support return to normal activities.

Common elements of post-treatment rehabilitation include:

• Night extension splinting: Wearing a splint at night to maintain finger extension, typically for 3-6 months
• Scar management: Massage and silicone gel application for surgical wounds
• Range of motion exercises: Both active and passive exercises to maintain flexibility
• Gradual return to activities: Progressive increase in hand use based on healing

Compliance with post-treatment rehabilitation recommendations significantly influences outcomes. Patients who adhere to splinting and exercise protocols generally achieve better long-term results than those who do not.

Can Dupuytren's Contracture Be Prevented?

There is no proven way to prevent Dupuytren's contracture from developing. Because the condition is largely determined by genetic factors, prevention strategies are limited. Maintaining good general health, managing diabetes well, avoiding smoking, and limiting alcohol consumption may help reduce risk or slow progression, but these measures have not been proven to prevent the disease.

The strong genetic component of Dupuytren's contracture means that individuals with a family history of the condition are likely to develop it regardless of lifestyle modifications. However, understanding modifiable risk factors may help some individuals reduce their risk or potentially slow disease progression.

For individuals at risk or with early disease, the following general recommendations may be considered, though none have been proven to prevent Dupuytren's contracture:

• Optimize diabetes control: Good glycemic management may reduce complications in diabetic patients
• Stop smoking: Smoking cessation benefits overall health and may reduce fibrotic processes
• Moderate alcohol consumption: Excessive alcohol use is associated with higher risk
• Monitor hand changes: Early awareness allows timely treatment if needed

There is no evidence that exercises, stretching, or avoiding manual work prevents Dupuytren's contracture in genetically susceptible individuals. Similarly, no vitamins, supplements, or medications have been proven to prevent the condition.

What Is the Long-Term Outlook for Dupuytren's Contracture?

Dupuytren's contracture is a chronic, progressive condition that cannot be permanently cured with current treatments. However, effective treatments can restore hand function when contracture becomes problematic. Most people with Dupuytren's maintain good hand function throughout their lives with appropriate monitoring and timely intervention when needed. Recurrence after treatment is common and may require repeat procedures.

The prognosis for Dupuytren's contracture varies considerably depending on individual factors. Many people with the condition have mild disease that never significantly impacts their daily activities and may not require treatment. Others experience progressive contracture that benefits from intervention, potentially multiple times over their lifetime.

Several factors are associated with a more favorable prognosis:

• Later age at onset (over 50 years)
• Single digit involvement
• No family history
• Unilateral (one hand) involvement
• Absence of Dupuytren's diathesis features

Conversely, factors suggesting a more aggressive course and higher recurrence risk include:

• Young age at onset (before 50)
• Strong family history
• Bilateral involvement
• Multiple digit involvement
• Presence of ectopic disease (Ledderhose, Peyronie's, knuckle pads)

With modern treatment options and appropriate rehabilitation, most patients achieve satisfactory improvement in hand function. The key to successful long-term management is understanding that Dupuytren's contracture is a chronic condition requiring ongoing monitoring and potentially multiple treatments over time, rather than a problem that can be permanently fixed with a single intervention.