Dupuytren’s contracture is a progressive disorder that starts gradually, with small, tender lumps in the palm of the hand. Over time, fingers (usually the ring and/or small fingers) are drawn into a bent position. As Dupuytren’s worsens, people find it difficult to perform such routine activities as washing their hands or grasping large objects.
Dupuytren’s has no cure, but Yale Medicine offers several effective treatments that can improve hand function significantly. Carrie Swigart, MD, chief of Yale Medicine Hand & Upper Extremity Surgery Program, has been treating Dupuytren's for decades.
What is Dupuytren’s contracture?
Dupuytren’s contracture is a benign thickening of the palmar fascia (a dense network of fibers that gives the palm skin its stability), characterized by the presence of excess collagen. Small nodules or indentations are usually the first signs of Dupuytren’s. Later, thick cords form that draw the affected fingers down towards the palm. Dupuytren’s typically appears after age 40 and grows more common with age. It more prevalent in men than women. The younger a person is when Dupuytren’s develops, the more severe the condition is likely to become.
What causes Dupuytren’s contracture?
According to Dr. Swigart, family history of Dupuytren’s raises your risk of getting it. Though it’s not yet clear why some people develop Dupuytren’s and others don’t, she says that research has unearthed several intriguing trends, including:
- People with diabetes and/or alcoholism are at higher risk.
- Risk is elevated with prolonged (over many, many years) with exposure to cold temperatures, particularly in people whose hands are sensitive to cold.
- Some people with Dupuytren’s get lumps or thickenings in other body parts, including the tops of the knuckles and soles of the feet.
How is Dupuytren’s contracture diagnosed?
No imaging or blood tests exist to confirm the presence of Dupuytren’s contracture. “It’s purely a clinical finding,” says Dr. Swigart. She says the diagnosis is based on patient-reported symptoms, observation and physical exam findings.
How is Dupuytren’s contracture treated?
Until recently, the only help doctors could offer to people with Dupuytren’s was surgical removal of the thickened, contracted tissue. That approach works well, and for some patients whose cords are in certain locations or patterns, it remains the best option, says Dr. Swigart.
The outpatient surgical procedure uses a nerve block to numb the entire arm. Dr. Swigart describes recovery as “mid-level painful,” because no bone is involved. Long incisions across the palm, and into the fingers, are usually needed to reach all affected tissue. Most patients require physical therapy to regain strength and range of motion. A full recovery and return to activities (such as playing golf) takes six to eight weeks.
Faster, easier and less painful is a new treatment involving an injection of Xiaflex (the brand name for clostridium collagenase). Xiaflex (pronounced zie-a-flex) is an enzyme made from the bacterium clostridium that dissolves collagen. Treatment with Xiaflex begins with an in-office injection directly into the thickened tissue. It stings a bit, like any injection, Dr. Swigart says, but is not especially painful.
Two days later, the patient treated with Xiaflex returns to the office and receives a local anesthetic to numb the affected area. Then, Dr. Swigart says, “I manipulate the finger passively, stretch it and straighten it out, and then break the cord, nonsurgically.” Patients wear a splint at night to hold the finger straight and prevent it from curling up again; some require physical therapy to help expand range of motion in fingers that haven’t been used for a while.
The surgical procedure and Xiaflex are about equally effective, Dr. Swigart says, and both bring lasting results. But, she says, “It’s common for Dupuytren’s to recur, sometimes vigorously.”
What makes Yale Medicine's approach to Dupuytren’s contracture unique?
Because they participate in clinical trials, Yale Medicine’s physicians are often among the first to use new therapies, such as Xiaflex, which even now is not widely available in community hospitals, says Dr. Swigart who has honed her skills using Xiaflex over many procedures. “The more you do this, the better you get at it,” she says.
“Not everyone is the ideal candidate for Xiaflex,” Dr. Swigart says. “Some patients come in and request it specifically, but it’s not right for them. Others come in expecting to need surgery, and we can introduce this as a really good option. So you really want to find a surgeon who is comfortable and has experience doing both types of treatments.”