Dupuytren’s contracture is a progressive condition affecting the hand, characterized by the abnormal thickening of the fascia, a layer of tissue located just beneath the skin of the palm and fingers. This process begins with the formation of small, firm nodules that develop into tight, rope-like cords. As these cords contract, they pull the fingers toward the palm, making it difficult or impossible to fully straighten the affected digits. The condition most commonly impacts the ring and pinky fingers, leading to a loss of hand function that prompts individuals to seek medical care.
Primary Medical Specialists
The treatment for Dupuytren’s contracture falls primarily under the care of specialized hand surgeons. A hand surgeon is a physician who has completed training in orthopedic, plastic, or general surgery, followed by a dedicated fellowship focused on the anatomy and function of the hand and upper extremity. This training provides the necessary expertise to manage issues from delicate nerve preservation to complex reconstructive procedures.
Many patients are treated by Orthopedic Surgeons who have completed fellowship training in hand surgery. These specialists focus on conditions of the musculoskeletal system and are skilled in surgical techniques for correcting joint and soft tissue deformities. Their background ensures a deep understanding of the tendons, bones, and ligaments affected by the contracting fascia.
Plastic Surgeons who specialize in reconstructive hand surgery also frequently treat this condition. Their expertise in managing skin and soft tissue, including the use of skin grafts, is valuable in advanced cases where the diseased tissue has adhered to or distorted the overlying skin. Regardless of their initial surgical residency, the common denominator for treating Dupuytren’s contracture is the completion of a specialized hand surgery fellowship.
Initial Consultation and Diagnosis
Diagnosis of Dupuytren’s contracture is primarily based on a physical examination of the hand. The specialist will take a detailed medical history, noting the onset and progression of the thickening and any family history, as the condition often has a genetic component. They will visually inspect the palm for characteristic signs, such as skin pitting or the presence of firm nodules and longitudinal cords.
The physician will use palpation, pressing on the palm to feel for the cords of tissue and confirm they are distinct from the underlying tendons. A defining part of the examination is the “table-top test,” a simple functional assessment. If the patient cannot place their hand completely flat, palm-down, on a flat surface, the test is positive, indicating a contracture severe enough for intervention consideration. The degree of contracture at the finger joints is also measured using a goniometer to track the disease progression.
Management and Treatment Modalities
For mild cases presenting only as nodules without significant contracture, the initial approach is observation, commonly referred to as “watchful waiting.” Since the condition can progress slowly or even stop, monitoring the hand’s function and contracture severity is the first step. Active intervention is reserved for when the contracture begins to impair daily activities.
One non-surgical option is Collagenase Clostridium histolyticum, a medication injected directly into the Dupuytren’s cord. This enzyme chemically breaks down the collagen proteins that form the fibrotic cord. Following the injection, the physician manipulates the finger a day or two later to manually rupture the weakened cord and restore a straighter position.
Another minimally invasive technique is Needle Aponeurotomy, sometimes called Needle Fasciotomy. Performed under local anesthesia, this procedure uses a fine needle inserted through the skin to puncture and section the diseased cord at multiple points. The goal is to weaken the cord enough so the finger can be straightened, breaking the final bands of tissue without a large incision.
When non-surgical options are not appropriate or the contracture is severe, surgical interventions are utilized. The most common procedure is a Fasciectomy, where the surgeon makes an incision to remove the thickened, diseased palmar fascia cord. A partial or limited fasciectomy removes only the tissue causing the contracture, offering a more complete and potentially longer-lasting correction than the needle or enzyme methods.
In cases where the disease is extensive or has returned after previous treatment, a Dermofasciectomy may be performed. This involves removing the diseased fascia and the tightly adhered, overlying skin, which is then replaced with a skin graft. This more aggressive approach is necessary for severe contractures, particularly those involving the middle joint of the finger, and carries a lower risk of recurrence in that area.
Timing for Medical Intervention
The decision to move beyond observation and pursue active treatment is determined by the degree of functional impairment. A patient should seek intervention when the contracture interferes with daily life, such as difficulty grasping large objects, fitting a hand into a glove, or performing hygiene tasks. The table-top test serves as a practical indicator that the disease has progressed to a stage where treatment may be beneficial.
Intervention is typically recommended when the contracture is greater than 30 degrees at the metacarpophalangeal joint (the knuckle closest to the palm), or any contracture at the proximal interphalangeal joint (the middle finger joint). Waiting too long risks permanent stiffening and secondary joint changes that can limit the final outcome, even after successful cord removal.