dupuytren's contracture dupuytren's contracture dupuytren's contracture (also called dupuytren's disease, morbus dupuytren, viking disease, palmar fibromatosis and celtic hand) is a condition in which one or more fingers become permanently bent in a flexed position. it is named after guillaume dupuytren, who first described the underlying mechanism of action, followed by the first successful operation in 1831 and publication of the results in the lancet in 1834. it usually begins as small, hard nodules just under the skin of the palm, then worsens over time until the fingers can no longer be fully straightened. while typically not painful, some aching or itching may be present. the ring finger followed by the little and middle fingers are most commonly affected. it can affect one or both hands. the condition can interfere with activities such as preparing food, writing, putting the hand in a tight pocket, putting on gloves, or shaking hands. not to be confused with dupuytren fracture. dupuytren's contractureother namesdupuytren's disease, morbus dupuytren, palmar fibromatosis, viking disease, and celtic hand, contraction of palmar fascia, palmar fascial fibromatosis, palmar fibromasdupuytren's contracture of the ring fingerpronunciation/dəˌpwiːˈtræ̃z, -ˈpwiːtrənz/ specialtyrheumatologysymptomsone or more fingers permanently bent in a flexed position, hard nodule just under the skin of the palmcomplicationstrouble preparing food or writingusual onsetgradual onset in males over 50causesunknownrisk factorsfamily history, alcoholism, smoking, thyroid problems, liver disease, diabetes, epilepsydiagnostic methodbased on symptomstreatmentsteroid injections, clostridial collagenase injections, surgeryfrequency~5% (us) the cause is unknown but might have a genetic component. risk factors include family history, alcoholism, smoking, thyroid problems, liver disease, diabetes, previous hand trauma, and epilepsy. the underlying mechanism involves the formation of abnormal connective tissue within the palmar fascia. diagnosis is usually based on a physical exam. blood tests or imaging studies are not usually necessary. initial treatment is typically with a cortisone shot into the affected area, occupational therapy, and physical therapy. among those who worsen, clostridial collagenase injections or surgery may be tried. radiation therapy may be used to treat this condition. the royal college of radiologists (rcr) faculty of clinical oncology concluded that radiotherapy is effective in early stage disease which has progressed within the last 6 to 12 months. the condition may recur despite treatment. if it does return after treatment, it can be treated again with further improvement. it is easier to treat when the amount of finger bending is more mild. it was once believed that dupuytren's most often occurs in white males over the age of 50 and is rare among asians and africans. it sometimes was erroneously called "viking disease," since it was often recorded among those of nordic descent. in norway, about 30% of men over 60 years old have the condition, while in the united states about 5% of people are affected at some point in time. in the united kingdom, about 20% of people over 65 have some form of the disease. more recent and wider studies show the highest prevalence in africa (17 percent), asia (15 percent). signs and symptoms dupuytren's contracture of the right little finger. arrow marks the area of scarring. typically, dupuytren's contracture first presents as a thickening or nodule in the palm, which initially can be with or without pain. later in the disease process, which can be years later, there is painless increasing loss of range of motion of the affected finger(s). the earliest sign of a contracture is a triangular "puckering" of the skin of the palm as it passes over the flexor tendon just before the flexor crease of the finger, at the metacarpophalangeal (mcp) joint. generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. the most common finger to be affected is the ring finger; the thumb and index finger are much less often affected. the disease begins in the palm and moves towards the fingers, with the metacarpophalangeal (mcp) joints affected before the proximal interphalangeal (pip) joints. the mcp joints at the base of the finger responds much better to treatment and are usually able to fully extend after treatment. due to anatomic differences in the ligaments and extensor tendons at the pip joints, they may have some residual flexion. proper patient education is necessary to set realistic treatment expectation. in dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. the main function of the palmar fascia is to increase grip strength; thus, over time, dupuytren's contracture decreases a person's ability to hold objects and use the hand in many different activities. dupuytren's contracture can also be experienced as embarrassing in social situations and can affect quality of life people may report pain, aching, and itching with the contractions. normally, the palmar fascia consists of collagen type i, but in dupuytren patients, the collagen changes to collagen type iii, which is significantly thicker than collagen type i. related conditions people with severe involvement often show lumps on the back of their finger joints (called "garrod's pads", "knuckle pads", or "dorsal dupuytren nodules"), and lumps in the arch of the feet (plantar fibromatosis or ledderhose disease). in severe cases, the area where the palm meets the wrist may develop lumps. it is thought the condition peyronie's disease is related to dupuytren's contracture. in one study those with stage 2 of the disease were found to have a slightly increased risk of mortality, especially from cancer. risk factors many risk factors have been suggested or identified: non-modifiable people of scandinavian or northern european ancestry; it has been called the "viking disease", though it is also widespread in some mediterranean countries, e.g., spain and bosnia. dupuytren's is unusual among groups such as chinese and africans. men rather than women; men are more likely to develop the condition (80%) people over the age of 50 (5% to 15% of men in that group in the us); the likelihood of getting dupuytren's disease increases with age people with a family history (60% to 70% of those affected have a genetic predisposition to dupuytren's contracture) modifiable smokers, especially those who smoke 25 cigarettes or more a day thinner people, i.e., those with a lower-than-average body mass index. manual work alcohol consumption in january 2023, a research paper "dupuytren's disease is a work-related disorder: results of a population-based cohort study" showed the clear link between manual work and the condition. the study was by researchers at the university of groningen medical centre, netherlands and oxford university, uk. they found those with jobs that always or usually involved manual work were 1.29 times more likely to develop dupuytren's disease than those who rarely or never performed it. they identified a linear dose-response relationship with cumulative manual labour over a 30-year period. other conditions people with a higher-than-average fasting blood glucose level people with previous hand injury people with ledderhose disease (plantar fibromatosis) people with epilepsy (possibly due to anti-convulsive medication) people with diabetes mellitus people with hiv previous myocardial infarction diagnosis types according to the american dupuytren's specialist dr. charles eaton, there may be three types of dupuytren's disease: type 1: a very aggressive form of the disease found in only 3% of people with dupuytren's, which can affect men under 50 with a family history of dupuytren's. it is often associated with other symptoms such as knuckle pads and ledderhose disease. this type is sometimes known as dupuytren's diathesis. type 2: the more normal type of dupuytren's disease, usually found in the palm only, and which generally begins above the age of 50. according to eaton, this type may be made more severe by other factors such as diabetes or heavy manual labor. type 3: a mild form of dupuytren's which is common among diabetics or which may also be caused by certain medications, such as the anti-convulsants taken by people with epilepsy. this type does not lead to full contracture of the fingers, and is probably not inherited. treatment treatment is indicated when the so-called table-top test is positive. with this test, the person places their hand on a table. if the hand lies completely flat on the table, the test is considered negative. if the hand cannot be placed completely flat on the table, leaving a space between the table and a part of the hand as big as the diameter of a ballpoint pen, the test is considered positive and surgery or other treatment may be indicated. additionally, finger joints may become fixed and rigid. there are several types of treatment, with some hands needing repeated treatment. the main categories listed by the international dupuytren society in order of stage of disease are radiation therapy, needle aponeurotomy (na), collagenase injection, and hand surgery. as of 2016 the evidence on the efficacy of radiation therapy was considered inadequate in quantity and quality, and difficult to interpret because of uncertainty about the natural history of dupuytren's disease. needle aponeurotomy is most effective for stages i and ii, covering 6–90 degrees of deformation of the finger. however, it is also used at other stages. collagenase injection is likewise most effective for stages i and ii. however, it is also used at other stages. hand surgery is effective at stage i to stage iv. surgery on 12 june 1831, dupuytren performed a surgical procedure on a person with contracture of the 4th and 5th digits who had been previously told by other surgeons that the only remedy was cutting the flexor tendons. he described the condition and the operation in the lancet in 1834 after presenting it in 1833, and posthumously in 1836 in a french publication by hôtel-dieu de paris. the procedure he described was a minimally invasive needle procedure. because of high recurrence rates, new surgical techniques were introduced, such as fasciectomy and then dermofasciectomy. most of the diseased tissue is removed with these procedures.recurrence rates are low. for some individuals, the partial insertion of "k-wires" into either the dip or pip joint of the affected digit for a period of a least 21 days to fuse the joint is the only way to halt the disease's progress. after removal of the wires, the joint is fixed into flexion, which is considered preferable to fusion at extension. in extreme cases, amputation of fingers may be needed for severe or recurrent cases or after surgical complications. limited fasciectomy hand immediately after surgery, and completely healed limited/selective fasciectomy removes the pathological tissue, and is a common approach. low-quality evidence suggests that fasciectomy may be more effective for people with advanced dupuytren's contractures. during the procedure, the person is under regional or general anesthesia. a surgical tourniquet prevents blood flow to the limb. the skin is often opened with a zig-zag incision but straight incisions with or without z-plasty are also described and may reduce damage to neurovascular bundles. all diseased cords and fascia are excised. the excision has to be very precise to spare the neurovascular bundles. because not all the diseased tissue is visible macroscopically, complete excision is uncertain. a 20-year review of surgical complications associated with fasciectomy showed that major complications occurred in 15.7% of cases, including digital nerve injury (3.4%), digital artery injury (2%), infection (2.4%), hematoma (2.1%), and complex regional pain syndrome (5.5%), in addition to minor complications including painful flare reactions in 9.9% of cases and wound healing complications in 22.9% of cases. after the tissue is removed the incision is closed. in the case of a shortage of skin, the transverse part of the zig-zag incision is left open. stitches are removed 10 days after surgery. after surgery, the hand is wrapped in a light compressive bandage for one week. flexion and extension of the fingers can start as soon as the anaesthesia has resolved. it is common to experience tingling within the first week after surgery. hand therapy is often recommended. approximately 6 weeks after surgery the patient is able completely to use the hand. the average recurrence rate is 39% after a fasciectomy after a median interval of about 4 years. wide-awake fasciectomy limited/selective fasciectomy under local anesthesia (la) with epinephrine but no tourniquet is possible. in 2005, denkler described the technique. dermofasciectomy dermofasciectomy is a surgical procedure that may be used when: the skin is clinically involved (pits, tethering, deficiency, etc.) the risk of recurrence is high and the skin appears