A Dupuytren’s contracture is when the skin and soft tissue in the palm of the hand forms a nodule of hard tissue that pulls one or more of the fingers down into the palm. At first it will start as a small bump on the top part of the palm of your hand. It will progressively grow to become harder and bigger while pulling your finger down more and more, until you are eventually unable to straighten the finger(s) at all.
What is the Dupuytren’s contracture made up of?
Dupuytren’s contracture involves a layer of soft tissue just below the skin on the palm of your hand called the palmar fascia. The palmar fascia becomes abnormally thick, creating a cord that pulls down the fingers into your hand. Tendons, nerves and blood supply all run below this layer, but is usually uninvolved. Only when the contacture has been there for years, other structures like nerve, tendons and blood vessels are implicated.
What does the palmar fascia do?
The palmar fascia is a fibrous layer that covers the palm area from the wrist up to the fingers. It keeps all the underlying structures in place like a pool net or like a spider web that keeps all the strands attached. The fascia has multiple fibres connecting together forming a solid layer. This layer moves with the fingers and hand.
The Palmar Fascia contracts and expands in conjunction with all the surrounding tissue, keeping it all connected and in place.
How does a Dupuytren’s contracture happen?
A Dupuytren’s contracture is a progressive development that involves abnormal thickening of the palmar fascia. It’s still unknown why the fascia starts thickening. Research suggests that a trigger for this thickening can either be trauma or other connective tissue disorders. This leads your fascia to concentrate forces onto a single point which leads to the fascia to start thickening.
The fascia thickening will start slow with a small lump forming below the skin. Most often it will start just below the ring or little fingers, spreading to the middle and index fingers. It grows to form a hard mass on the palm of the hand that pulls the fingers down one by one over time. Resulting in your fingers stuck in a bent position.
A contracture of the facia is when the web-like connections starts to join the surrounding nerves, tendons and blood vessels to make a bundle of tissue unable to work like it should. When the contracture is present it restricts the natural movement of the fascia, skin, tendons, nerves and blood vessels. The larger the nodule develops, the more these surrounding structures are involved.
Causes of a Dupuytren’s contracture
The true cause of Dupuytren’s contractures are unknown, but the possibility is high in the following:
Hereditary: You can inherit the gene that causes abnormal thickening of the palmar fascia. It is most common in men from 45 years and older. People with an inherited disorders like muscular dystrophy also have a high chance of developing these types of contractures.
Trauma: An injury to the palmar fascia can cause scar tissue to form in the palm of the hand that can lead to the fascia thickening, causing a contracture.
Medical diagnosis: Your chances of developing a Dupuytren’s contracture are high if you have; diabetes, epilepsy, rheumatoid arthritis, alcoholism
Neurological conditions: Cerebral palsy, stroke and polio patients can develop Dupuytren’s contractures
Symptoms of Dupuytren’s contracture
- Lumps or nodules under the skin on the palm of the hand
- The lumps may be sensitive at first but the discomfort eases over time
- Stretching feeling over the palm of the hand when straightening your fingers
- Hard bands of connective tissue from your palm moving up to the fingers
- Difficulty to open the fingers
- Problems with placing the hand flat on a table
- Fingers stuck in the palm of the hand
- Severe difficulty trying to open the hand
- Unable to hold larger objects because the fingers cannot straighten
- You are unable to reach into pockets of your pants as the fingers won’t straighten
- Cannot shake hands with someone
- Inability to carry objects in the palm of the hand as the fingers are in the way
- Are you able to open your finger(s) without using your other hand?
- Are you able to push with your hand onto a table, keeping your palm and finger on the table at the same time?
- Can you make a fist, and then open your hand to place it against a wall?
- Can you catch a ball?
How bad is it?
If you experience stiffness in your fingers and tightness in the palm of your hand while trying to straighten your fingers, you may be at the start of the first phase. If you are unable straighten your fingers without the help of your other hand, or you’d have to force it open, you are in the second phase – It’s still salvageable.
Once the contracture has formed & you’re fingers are stuck, you will need surgical intervention.
How we test it:
We are experienced in testing the different types of problems that can cause your hand & finger problem. Our specialists use a variety of clinical evaluations to determine the extent of the damage. We develop a certain dexterity to detect a problem and distinguish if the nerves, blood vessels or tendons are involved, before any scans are indicated.
If your test results prove that we suspect that you may have another problem relating to the fascia, we will require further investigation. The first on the list will be a Sonar.
X-rays will be an unnecessary test, as the bones are still normal, and the joints are not influenced. So X-rays will be redundant in this case.
This is a very useful tool to see in detail the extent of the damage, but any skilled hand therapist will be able to diagnose a Dupuytren’s contracture without an expensive MRI. An unnecessary test to be performed.
Sonar (Diagnostic Ultrasound):
A sonar can determine the thickness and degree of abnormality of the palmar fascia. It will show the size and magnitude of the problem. This would be the best way to assess the palmar fascia & a Dupuytren’s Contracture.
Why is this not going away?
The contracture in fascia of the palm of your hand will not resolve or disappear without medical assistance. It involves a complex procedure to get the surrounding structures to move freely. An attempt to resolve this on your own you may end up causing more harm.
What makes Dupuytren’s contracture Worse
Ignoring the problem is one of the worst things you can do. If you are not actively trying to improve the problem, it’ll only get worse in time.
Continuing to try and use the fingers in this bent position. Compensating for the problem does not resolve it – it’s only a temporary solution. Before you know, it may complicate your situation even more, causing nerve entrapment, tendon shortening and decreased blood supply to areas of your hand & finger.
A big problem we see with a Dupuytren’s contracture these days:
Surgery attempts to completely remove the palmar fascia. After a patient has surgery, scar tissue forms. Scar tissue is a dense tissue that looks like a spider web. It helps to close a wound very well, but in some cases it can restrict the normal slide of the tendon, nerve & blood vessels.
This can be quite counterproductive; seeing that this is what caused the loss of movement in your fingers in the first place and leading to a never ending cycle. Consulting a trained therapist is very important to ensure that scar tissue is guided to prevent any restriction on the skin and underlying tendons, nerves & blood vessels.
Waiting too long
When you wait too long before getting treatment the contracture can become stiff, hard & firm leaving the fingers in a permanent bent position. If the contracture progresses too far there can be soft tissue implications that will leave you needing skin grafts and other soft tissue reconstruction when it’s finally surgically released.
This implicaties the length and severity of the rehabilitation process, making it very difficult to regain full use of the hand. Research has shown that if moderate symptoms occur for longer than 6 months the effects of conservative treatment is less successful to regain full function.
OT treatment for Dupuytren’s contracture:
Splinting – Sustaining the hand fascia in a stretched position, is vital to prevent the fingers and palm to bend. A hard splint is used to ensure ideal position.
Exercises – We focus on keeping the muscles and tendon gliding and contracting like it should. Will gradually progress you on a program to challenge the tendons & muscles at different ranges.
Tendon gliding – Getting the tendon free from the obstruction, and the restoring its normal slide through the palm.
Strength training: The tendon will need gradual loading exercises to recondition the tendon.
Sensory retraining – To restore the normal feeling in your fingers, the the nerve is affected.
Oedema management – Reduce swelling in and around the hand and fingers
Ergonomics – Changing or adapting activities, tasks or the environment to reduce the risk of a repetitive strain or injury.
Phases of Rehabilitation & Treatment:
1st Phase: Prevent the Contrature getting worse
Education & assessment of daily activities to determine contributing factors and activities that must be avoided.
2nd Phase: ‘Normal position’
Use of Splinting, loading exercises to regain the normal open hand position.
3rd Phase: Regain normal Finger Range of movement
Allow fingers joints, tendons, & nerves to move independently.
4th Phase: Grip & Muscle Strength
Regain normal grip. Opposition of fingers & forearm flexor muscle strength by grading scale of muscle contraction focussing on eccentric and concentric contractility.
5th Phase: Dexterity & Fine motor skills
Able to perform intricate & delicate actions using the fingers & hand. Retraining the sensitivity & magnitude of contractions performed by the forearm flexor muscle group.
6th Phase: Return to full function & Participation
Able to catch an incoming ball, reflex testing, reaction ball retraining. Fast response & grading of movement pattern.
Without surgery we are able to restore it to normal function using our 12 week program.
You will need a comprehensive rehab program after your surgery and it may take up to 6 months to recover. We suggest you consult a health care professional if you are uncertain regarding your hand pain.
Most cases end up having surgery due to poor initial management & patient neglect to recognise the problem.
Surgery of a Dupuytren’s contracture
Surgery attempts to completely remove the palmar fascia. Fasciotomy (‘otomy’ meaning opening/ release of… in this case fascia). After a patient has surgery, scar tissue forms. Scar tissue is a dense tissue that looks like a spider web. It helps to close a wound very well, but in some cases, it can restrict the normal slide of the tendon, nerve & blood vessels.
This can be quite counterproductive seeing that this is what causes the loss of movement in your fingers in the first place.
Dupuytren’s contracture is also Known as:
- Dupuytren’s disease
- Palmar fibromatosis
What needs to be tested to determine the source of your hand pain
Range of Movement
Nerve tension test
Tendon gliding test