Dupuytren's Contracture

Dupuytren's Contracture

Dupuytren's contracture (DC) is an abnormality of collagen under the skin of the hand from the palm to the fingers. This collagen forms nodules that are rich with myofibroblasts that promote new cell growth. and then shortens, pulling fingers toward the palm so that the fingers can not straighten and the hand cannot open or flatten. The ring finger is the most commonly affected finger in DC, followed by the little finger, although all the fingers can be bent.

The cause of Dupuytren's contracture is unclear. People who have a higher incidence of DC are men over 50 of northern European (Viking) ancestry and people who do manual labor that abuses the hands. Many people with diabetes are affected by DC as well as by thickening of the skin of the finger tendons that can decrease joint mobility and limit finger extension. People with Type 1 and Type 2 diabetes are about 5% of all people with DC. This may be because of DC's relation to low insulin levels. People often presenting with DC include alcoholics, smokers, epileptics, people taking glucosamine/chondroitin, barbiturates, or HIV medications, people with deficiencies in critical vitamins and minerals, especially Vitamins B-6, B-12 and D and people with hypothyroidism and other endocrine problems.

DC is progressive and may advance at a constant rate or in spurts. While treatment on the hands to relieve the contracture is important, DC often returns as a part of the healing process. Treating the underlying causes may be essential to help avoid the progression and recurrence of DC. A key step for someone with diabetes and DC is to keep the glucose in good control and avoid the glycosylation and insulin resistance of high blood glucose. A healthy diet and exercise are also recommended. Supplementation with a Vitamin B complex, Vitamin D and the minerals magnesium, zinc, and calcium is important.

Until recently the primary treatment consisted of surgery. The risks of surgery in which the collagen is removed from the hand include infections and damage to nerves and arteries. Recovery takes weeks to months and physical therapy is often required. Another procedure in use is needle aponeurotomy in which the cords of collagen are broken apart by poking them repeatedly with a needle through the skin. This procedure is less costly than surgery and has been in use for 30 years.

The newest treatment just on the market is Xiaflex, an enzyme that dissolves collagen, injected directly into the cord. The next day therapy begins to straighten out the finger or fingers. Several injections, spaced over months, might be needed, especially if more than one finger is affected. One side effect, though rare, is complete rupture of a tendon. The injections can also cause temporary pain, bruising, swelling and occasional allergic reactions. Xiaflex is priced around $3,250 per injection.

In a small clinical trial of 306 patients, 64% had sufficient straightening so that the hand can be opened. However, it is uncertain how long the improvement will last since long term studies have not been made.