Dupuytren's contracture

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Dupuytren's contracture is a slow growing inflammatory thickening on the palm of the hand that eventually creates a deformity of the ring and little finger. It was  first reported in the Lancet in 1831 by the French surgeon Guillaume Dupuytren. Although medical interventions may be required eventually, we describe here lifestyle and self help strategies which help relieve the discomfort especially in the early stages and  help delay progression and deformity.

Early symptoms; Dupuytren's contracture usually begins as a fibrous thickening of the skin on the palm of your hand. As Dupuytren's contracture progresses, the skin on the palm of your hand may appear puckered or dimpled. A firm lump of tissue may form on your palm. This lump may be sensitive to the touch but usually isn't painful.

Later symptoms; In later stages of Dupuytren's contracture, cords of tissue form under the skin on your palm and may extend up to your fingers. As these cords tighten, your fingers may be pulled toward your palm, sometimes severely. Once this occurs, the fingers affected by Dupuytren's contracture can't be straightened completely, which can complicate everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands. Only rarely are the thumb and index finger affected. Dupuytren's contracture can occur in both hands, though one hand is usually affected more severely than the other

Underlying causes; 

The deformity is caused by fibrosis and thickening around the tendon sheaths of the hand which eventual contract. Why these form in the first place is unknown although it is known to be associated with:

• Age. Dupuytren's contracture occurs most commonly after the age of 50.
• Cancer treatments; Particularly long term hormone therapies suc as aroatase inhibitors
• Sex. Men are more likely to develop Dupuytren's and to have more severe contractures than are women.
• Ancestry. People of Northern European descent are at higher risk of the disease.
• Family history. Dupuytren's contracture often runs in families.
• Tobacco Smoking is associated with an increased risk, perhaps because of microscopic changes within blood vessels caused by smoking.
• Alcohol High alcohol intake is associated with an increased risk especially if cirrhosis develops
• Other lifestyle factors: Lack of exercise and high saturated fat and low low omega 3 intake low antioxidant/polyphenol  intake
• Diabetes. People with diabetes are reported to have an increased risk of Dupuytren's contracture
• Medication; Drug including phenytoin and  aromatse inhibitors

Dupuytren's contracture most commonly affects the ring finger and little, and occurs most often in older men of Northern European descent. A number of treatments are available to slow the progression of Dupuytren's contracture and relieve symptoms

Lifestyle and self help strategies:

1. Stretch

• Gently bend your fingers backward from your palm.
• Place your fingers on the edge of a table, palm down, and then lift the palm upward gradually, as you keep your fingers flat on the table.
• Rotate the wrist from side to side
• Put your hand in a prayer position pushing the palms and fingers together
• Do not over stretch and cause pain which may be counter productive
• See the film on keep-healthy.com

2. Massage / oils

• Before stretching, warm up your hands in warm water or a heat pad
• Avoid heavily scented creams
• Avoid creams with hydrocarbons and artificial irritation ingredients
• Use a natural plant based moisturiser with natural anti-inflammatory properties (e.g natureMedical Dupuytrens relief balm)
• Massage your palms in all directions on and around the thickening

3. Protect your hands:

• Avoid a tight grip on tools by building up the handles with pipe insulation or cushion tape.
•  Use gloves with heavy padding during heavy grasping tasks.

4. Improve your general heath, particularly:

• Try to reduce chronic inflammation - tips
• Stop smoking - see tips to quit
• Reduce alcohol intake - see alcohol advice
• Exercise regularly - see exercise tips and  exercise classes/facilities in your area
• Ensure  adequate intake of Omega 3 fatty acids  - more about health fats
• Kick start the anti-inflammatory process with a course of CBD cannabis oils - more
• Ensure adequate intake of health plant based anti-oxidant polyphenol rich foods - more

Medical interventions

If the disease progresses slowly, causes no pain and has little impact on your ability to use your hands for everyday tasks, you may not need treatment. Instead, you may choose to wait and see if Dupuytren's contracture progresses.

Treatment involves removing or breaking apart the cords that are pulling your fingers in toward your palm. This can be done in several different ways. The choice of procedure depends on the severity of your symptoms and any other health problems you may have.

Needling
This technique uses a needle, inserted through your skin, to puncture and "break" the cord of tissue that's contracting a finger. Contractures often recur but the procedure can be repeated. Some doctors now use ultrasound to guide the needle. This might reduce the chance of accidental injury to nerves or tendons.

The main advantages of the needling technique are that there is no incision, it can be done on several fingers at the same time, and usually very little physical therapy is needed afterward. The main disadvantage is that it cannot be used in some locations in the finger, because it could damage a nerve.

Enzyme injections
The Food and Drug Administration has recently approved injections of an enzyme, collagenase clostridium histolyticum (Xiaflex) for the treatment of Dupuytren's contracture. The enzyme in this drug softens and weakens the taut cord in your palm. The day after the injection, your doctor will manipulate your hand in an attempt to break the cord and straighten your fingers.

In many ways, this is similar to the needling technique, except that the manipulation happens the next day, instead of during the injection procedure. The advantages and disadvantages of the enzyme injection are similar to needling, except that the enzyme injection may be more painful initially. Currently, enzyme injections can be used on only one joint at a time and treatments must be spaced at least a month apart.

Radiation therapy 
Radiotherapy is a non-surgical treatment that can stop or slow down Dupuytren's disease in its early stage. In radiation therapy, the nodules and cords associated with Dupuytren's are irradiated from a distance of .5 - 1 cm either with X-Rays (e.g. 120 kV = soft X-Rays that do not penetrate deeply into the body) or with electrons (3 - 10 MeV). This is typically done over five days in a row  ( total dose 15 Gy). After a break of six weeks, this treatment is repeated. 

Surgery
Another option is to surgically remove the tissue in your palm affected by the disease. This may be challenging because it's difficult to identify tissue in very early stages of the disease. Diseased tissue may also attach to the skin, making it difficult to remove and increasing the chances of recurrence.

The main advantage to surgery is that it results in a more complete joint release than that provided by the needle or enzyme methods. The main disadvantages are that physical therapy is usually needed after surgery, and the recovery time can be longer.

In some severe cases, surgeons remove all the tissue likely to be affected by Dupuytren's contracture, including the attached skin. In these cases a skin graft will be needed to cover the open wound. This surgery is the most invasive option and has the longest recovery time. People usually require months of intensive physical therapy afterward.