Hand and finger contractures are often caused by Dupuytren’s contracture. This progressive disease affects the connective tissue under the skin of the palm, the palmar fascia. The thick, strong, triangular fascia lies between the tendons and the skin, with attachments above and below, and extending to the fingers. As the palmar fascia thickens and shortens due to the disease, the fingers can be gradually pulled towards the palm and are unable to be fully straightened. The extent of the disease varies from person to person and is not predictable, although it is likely to be more aggressive if there is a family history of it, if you are male, if you are an alcoholic or suffer from epilepsy, if you have the disease in both hands, or if you have had surgery of the hand.
It often occurs in both hands, with the ring and little fingers predominantly affected, and rare involvement of the index finger or thumb.
Surgery or an injury always forms scar tissue as part of the healing process. If the scar tissue is in a position to affect normal movement of the wrist or finger joints, a contracture may result.
The causes of Dupuytren’s disease are not clear, although there is a definite genetic component with 60-70 per cent of sufferers reporting a family history of the condition.
Certain other factors are associated with Dupuytren’s. Although there is no evidence that they cause the disease, they certainly increase the risk of contracting it:
- Liver disease
- North European, especially Viking, ancestry.
- Being male: Men are three times as likely to contract Dupuytren’s as women.
- Age: Onset of the disease is more likely between the ages of 50-60.
The first symptom is likely to be small nodules in the palm of the hand, near the base of the fingers. These may be tender to begin with, but become painless with time.
The skin might begin to pucker, and painless cords might be visible under the skin of the palm, extending to the fingers.
When extending the fingers, the skin blanches, or loses color.
Occasionally there may be tenderness of the knuckles on the back of the hand.
At a later stage of progression, the skin and palmar fascia start to contract, pulling the fingertips towards the palm. It becomes impossible to fully straighten the fingers. Although all fingers can be affected, it is usually the ring and little fingers that suffer.
There can be a gradual onset of the disease, or a rapid acceleration followed by a period with no further changes.
Range of motion is restricted, and there is a reduction in normal hand function and ability.
Your doctor will take your full medical history and perform a careful physical examination. If the problem is a wrist contracture, questions about the onset of symptoms are vital in order to plan the correct course of treatment. The physical examination will reveal any visible symptoms such as lumps under the skin, puckered skin or cords. You will be asked to demonstrate the range of motion of your wrist, hand and fingers, and your doctor will note any limitations of joint movement. You may be asked to do a Hueston test, which involves trying to lay your palm flat on a tabletop. If you are unable to do this, your doctor might consider this a positive diagnosis of Dupuytren’s contracture.
Depending on which joints of the fingers are affected, you will be given a diagnosis of composite or fixed Dupuytren’s, and your condition graded from 0-5, according to the severity of the contracture.
X-rays are used as a diagnostic aid for a wrist contracture, to view any joint damage, but not for Dupuytren’s disease as an ultrasound is more useful in showing thickened fascia or the presence of any nodules.
There are two possible courses of action when deciding how to treat a wrist contracture. Which one is better depends on how mature the scar tissue is. If it is fairly recent, the most successful results can be achieved by wearing a splint on the wrist, and doing certain exercises to increase range of motion. If, on the other hand, the scar tissue is over three months old it is not possible to increase range of motion, so surgery is the better option. The aim of any surgery would be to remove as much scar tissue as possible in order to free up the joint, although it cannot be entirely removed and new scar tissue will form as a result of the surgery. Post-operatively, a splint would be worn continuously for 6 weeks, with gradual reduction of use over a few months, and the introduction of stretching exercises.
For Dupuytren’s contracture, treatment used to consist of ‘wait and see’, and observation is still recommended if the contracture is not causing any loss of function. In other cases, early treatment offers some hope of managing the disease, although if the contracture is severe you are not likely to recover completely normal hand function.
Needle aponeurotomy is a procedure used to separate the Dupuytren’s cords and restore mobility. This is performed on an outpatient basis and is preferable to surgery as it is less invasive and the formation of new scar tissue is reduced. After care includes wearing a splint for a few hours a day and not doing any sports or manual labor for one week.
If required, surgery is performed to remove the palmar fascia. Recurrence of the disease after surgery is possible, complications may occur, and rehabilitation is lengthy. A splint must be worn continuously for six weeks, then at night for a further three months, gradually tapering off to being worn only at night.
What to look for in a splint:
A physical therapist will probably make recommendations about the best splint for you, but you might want to consider a couple of factors. When a splint has to be worn for an extended time, comfort of fit is extremely important. A padded, adjustable splint would probably provide the greatest benefit. In order to avoid developing skin problems, it should be constructed in such a manner that your skin can breathe and remain dry.
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