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Dupuytren’s Contracture

The tip of a mysterious pathological iceberg

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

Dupuytren’s contracture causes a slow and mostly painless thickening of the connective tissue (fascia) and tendons of the palm. It starts in the palm — the earliest sign is a triangular puckering of the skin — and creeps towards the fingers, mostly the ring and pinkie fingers, which flex permanently. The hand will not lie flat on a table, as though it has an arch like a foot. In the most extreme cases, the finger bones can fuse and warp.

This mostly affects aging white men, but it has a list of other risk factors like alcoholism, manual labour, being skinny, hand injuries, diabetes, and smoking of course (it seems to be a risk factor for everything).

Dupuytren’s contracture (DC) has no other common name: just the tricky one, the legacy of French anatomist Guillaume Dupuytren (du-pwee-TREN), who first described it in 1883.1 Much more descriptively it sometimes also goes by palmar fascia fibromatosis or palmar fibromas. Or, more cryptically, it is known as Viking disease.2 Bagpipers call it the “Curse of the MacCrimmons.”3 But the eponymous mouthful is by far the dominant label.

A family of related, odd diseases

Whatever causes DC also affects some other tissues. There are closely related troubles in the knuckles (Garrod’s pads), foot (Ledderhose disease), shoulder (frozen shoulder), and — rather alarmingly — the penis (Peyronie’s disease).4 😮

Most people only have one of these, but they probably are all driven by the same biological glitch — it’s just a matter of which tissue is affected.5

If you have one, it does increase the risk of the others. A few people get more than one of them, because they have more of whatever the underlying biological malfunction is. When this worst-case scenario happens, it’s called Dupuytren’s Diathesis. It hits earlier, moves faster, and affects more fingers and probably both hands.

Diathesis makes it very clear that each of these diseases is the tip of a pathological iceberg. A biological cure is needed.

There is no cure, but there are treatments

You can’t stop a biological process you don’t understand. The malfunction at the root of Dupuytren’s contracture is still unexplained and therefore untreatable. However, some of its consequences can be partially managed in some patients.

In the early stages, or post-surgically, the condition might be slowed by a use-it-or-lose approach: exercise and stretching, primarily.

Ordinary stretching for contractures is definitely not effective,6 so it would be a happy surprise if Dupuytren’s contracture was an exception. Splinting is a little more promising, and there’s evidence it works for some other conditions.7 For all-night stretching, you can use a splint to keep the hand from flexing when you sleep. There are many types available commercially, and you can make them.8 Splinting appeared to be at least partially effective in a tiny 2012 study, one of the few scientific tests of this treatment ever published9… but (of course) that’s contradicted by a larger, better study.10 It’s a long shot, with the saving grace that there’s not a lot to lose.

Steroid injections might suppress the immune system activity (inflammation) that drives the disease, but this is a bit unlikely. Also more-or-less untested — it’s just one those “might make sense” treatments.

Treating it like a tumour and bombarding the palm with radiation can kill the cells that produce the excess tissue. There are some serious side effects to this, of course, so it had better work; unfortunately, it’s not clear that it does.11

Collegenase, an enzyme, dissolves connective tissue; injecting the right amount in the right place can dissolve the thickened cords that shorten the palm. The effectiveness is fairly well-established,12 but the side effects are a real concern.

Finally, the connective tissue of the palm can be cut or lacerated to loosen it. This, at least, is virtually guaranteed to have at least some beneficial effect — but even simple surgeries have risks, and recurrence of the condition after surgery is common.

Alternative medicine loves to offer (mostly ridiculous) treatments for incurable conditions, but the only notable one for Dupuytren’s contracture is vitamin E. Alas, it’s quite unlikely that it works.13


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

NovemberMore detail and references about stretching. Miscellaneous editing.

Notes

  1. As is so often the case, it was actually “discovered” (described) by someone else long before that: Henry Cline, in 1808. See “Cline’s Contracture: Dupuytren Was a Thief – A History of Surgery for Dupuytren’s Contracture.BACK TO TEXT
  2. Because Northern European men are most affected, though it is actually common throughout the Mediterranean. BACK TO TEXT
  3. The MacCrimmons were a family of well-known bagpipe players in 16th Century Scotland. Dupuytren’s contracture makes it impossible to pipe, and the condition is relatively common in Europeans. However, inflammatory arthritis is so much more common that I wonder how the curse ended up referring to such a relatively obscure condition! BACK TO TEXT
  4. Peyronie’s is very rare, but I have a friend who was stricken with it. Beating the odds, his troubling deformity actually regressed — a stroke of luck that only a small fraction of the afflicted enjoy. Presumably it is also possible for some cases of DC to regress. BACK TO TEXT
  5. This is a microcosm of a broader pattern in rheumatology. There are dozens of autoimmune diseases, but basically all of them involve the same process applied to different types of tissues in specific locations. Nearly any tissue in the body can be damaged by an overzealous immune system, creating dramatically different effects. There may be variation in how the immune system damages tissues as well, and DC might be a sub-type of autoimmune disease. BACK TO TEXT
  6. Harvey LA, Katalinic OM, Herbert RD, et al. Stretch for the treatment and prevention of contractures. Cochrane Database Syst Rev. 2017 Jan;1:CD007455. PubMed #28146605. PainSci #52742.

    This is a Cochrane review of static stretch for the treatment and prevention of contractures. The verdict? A clear thumbs down. Based on “high-quality evidence” they concluded that “stretch is not effective for the treatment and prevention of contractures.”

    BACK TO TEXT
  7. Furia JP, Willis FB, Shanmugam R, Curran SA. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther. 2013 Aug;30(8):763–70. PubMed #24018464. PainSci #52971. BACK TO TEXT
  8. Glue a glove to a thin but sturdy sheet of wood, metal, or plastic, to keep the hand flat as you sleep. BACK TO TEXT
  9. Larocerie-Salgado J, Davidson J. Nonoperative treatment of PIPJ flexion contractures associated with Dupuytren's disease. J Hand Surg Eur Vol. 2012 Oct;37(8):722–7. PubMed #21965179. BACK TO TEXT
  10. Jerosch-Herold C, Shepstone L, Chojnowski AJ, et al. Night-time splinting after fasciectomy or dermo-fasciectomy for Dupuytren's contracture: a pragmatic, multi-centre, randomised controlled trial. BMC Musculoskelet Disord. 2011 Jun;12:136. PubMed #21693044. PainSci #52736.

    150 patients received physical therapy for their Dupuytren’s contracture, with or without night splint usage. There was no difference by any measure, and so “routine addition of night-time splinting for all patients after fasciectomy or dermofasciectomy is not recommended.”

    BACK TO TEXT
  11. Kadhum M, Smock E, Khan A, Fleming A. Radiotherapy in Dupuytren's disease: a systematic review of the evidence. J Hand Surg Eur Vol. 2017 Mar:1753193417695996. PubMed #28490266. “On balance, radiotherapy should be considered an unproven treatment for early Dupuytren's disease due to a scarce evidence base and unknown long-term adverse effects. Well-designed randomized controlled studies are required to confirm the benefits of radiotherapy treatment.” BACK TO TEXT
  12. Gaston RG, Larsen SE, Pess GM, et al. The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study. J Hand Surg Am. 2015 Oct;40(10):1963–71. PubMed #26216077. “Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration.” BACK TO TEXT
  13. Richards HJ. Dupuytren's contracture treated with vitamin E. Br Med J. 1952 Jun;1(4772):1328. PubMed #14935247. PainSci #52875.

    ABSTRACT


    A series of 46 cases of Dupuytren’s contracture were treated; 24 had bilateral lesions. The patients were divided into three groups according to the degree of the deformity. Vitamn E was the sole form of treatment, and in no case was any improvement noted.

    This topic has barely been studied in the decades since this experiment. BACK TO TEXT