Dupuytren's contracture: why the fingers do not straighten and when surgery is needed - treatment in Tashkent

What is it: a disease of the palm, not the joint

Under the skin of the palm there is a dense fan-shaped plate - the palmar aponeurosis. It protects tendons, blood vessels and nerves, and also helps the skin not slip when grasping objects. With Dupuytren's disease, special cells begin to multiply in this plate, producing excess collagen and capable of contracting. The tissue is rebuilt: first a dense knot is formed, then a cord is formed from it, which gradually shortens and, like a stretched fishing line, pulls the finger towards the palm.

That is why it is useless to treat the joint here. The finger itself, its joints and flexor tendons are completely healthy in the early stages, and it is not the finger itself that prevents it from straightening, but the cord stretched under the skin. Working out, massage, stretching, physiotherapy and ointments have no effect on the rebuilt connective tissue - they can neither dissolve it nor lengthen it. Most often the ring and little fingers are affected, less often the middle finger, and extremely rarely the thumb. The process is usually bilateral, but develops asymmetrically, and the second arm can lag behind for years.

• The palmar aponeurosis is affected, not the joints or tendons
• Typical sequence: knot - cord - skin retraction - flexion contracture
• The pinky and ring fingers are most often affected.
• The process is usually painless, which explains the late application
• Both hands are usually affected, but at different rates
• The disease is chronic, lasts for years, with periods of calm and acceleration.

Who is sick and why

The cause of the disease has not been fully established, but factors that increase the likelihood have been well studied. The first place among them is heredity: the disease can often be traced in several generations, and in people with a family history it begins earlier and progresses more actively. The second most important factor is gender and age: men get sick several times more often than women, and the peak occurs after the age of fifty. In women, the disease usually begins later and is milder.

• Male gender - the disease occurs much more often in men
• Age over 50 years, although with a hereditary form the onset occurs earlier
• Family predisposition is the most significant factor
• Diabetes mellitus, especially long-term diabetes
• Smoking and alcohol abuse
• Taking certain anticonvulsants
• Northern European origin - the disease is historically associated with these populations
• Manual labor with vibration - discussed as a contributing factor, but not the main cause

Separately, it is worth mentioning the aggressive form of the disease. Signs that indicate it: onset before the age of fifty, involvement of both hands and several fingers, the presence of similar thickenings on the soles of the feet and a family history. In these patients, the disease progresses more quickly and relapses after surgery occur more often, which is important to consider when choosing a treatment option and when discussing expectations.

How it develops: from a nodule to a bent finger

The disease goes through fairly predictable stages, but the speed of their change is very individual: someone remains at the nodule stage for decades, for others it takes two or three years from the first changes to pronounced contracture. It is impossible to predict this in advance, so observation makes sense - what matters is not what is now, but how quickly the picture is changing.

1. Появление плотного безболезненного узелка на ладони, чаще напротив безымянного пальца или мизинца. Часто принимается за мозоль.
2. Кожа над узлом втягивается, теряет подвижность, появляются складки и ямки, которые невозможно расправить.
3. От узла формируется продольный тяж, натягивающийся под кожей при попытке разогнуть палец.
4. Начинает ограничиваться разгибание в основном суставе пальца — рука ещё функциональна, но ладонь уже не ложится ровно.
5. В процесс вовлекается средний сустав пальца — с этого момента полностью восстановить разгибание операцией удаётся не всегда.
6. Палец прижимается к ладони, страдает гигиена кожной складки, становятся невозможными привычные бытовые действия.

Pay attention to the turning point: as long as the extension of only the main joint of the finger is limited, the situation is almost completely reversible, because only the cord interferes. When the middle joint is involved in contracture, the finger’s own structures—the articular capsule and lateral ligaments—are shortened, and simply eliminating the cord becomes insufficient. This is why doctors do not approve of the phrase “I’ll wait until it gets worse”: the quality of the result depends on the stage at which treatment is started.

Tabletop test: how to understand for yourself that it’s time to see a doctor

There is a simple test invented specifically for this disease. Place your palm on a flat table surface and try to press it with the entire surface - your fingers and palm should lie flat. If there is a gap between the table and the finger where paper or a finger can be inserted, the test is considered positive. Traditionally, this moment is considered a reference point for talking about surgical treatment: it means that the contracture has reached a value at which it is already interfering with the function of the hand and will continue to increase.

• The palm rests completely on the table - observation time, treatment is usually not required
• There is a gap between the table and the finger - a reason to contact a hand surgeon
• Check both hands: the second hand often lags behind, but is also involved
• Take a photo of your palm on the table every few months - this is how you can see the rate of progression
• Additional guidance: it is impossible to put on a glove, wash your face, or pick up a large object
• A cord that stretches when trying to straighten a finger distinguishes the disease from a simple callus

Treatment: What Works and What Doesn't Exist

In the early stage, when there is only a nodule and the finger is fully extended, no active treatment is required - observation is sufficient. This is important to understand, because anxiety forces you to look for remedies that do not exist: there are no ointments, compresses, injections of absorbable drugs, devices or exercises that have been proven capable of stopping the restructuring of the aponeurosis or returning an already shortened cord to its previous length. Forcibly stretching the finger does not straighten it, and sometimes accelerates the process.

• Observation at an early stage is a reasonable and correct tactic
• Needle aponeurotomy: the cord is crossed with a needle through skin punctures, without an incision, under local anesthesia
• Open surgery - excision of the altered area of the aponeurosis, the most radical method
• Surgery with skin plastic surgery - for severe contracture and scarred skin
• Ointments, physiotherapy, massage, stretching - do not affect the course of the disease
• Radiation therapy at an early stage is discussed in selected cases, the decision is made individually

The choice between minimally invasive and open surgery is a choice between the speed of recovery and the durability of the result. Needle aponeurotomy is performed in a short time, almost without incisions, the arm is working within a few days, but the cord is not removed, but only crossed, so the contracture returns more often and earlier. Open surgery requires several weeks of recovery and full rehabilitation, but it removes the changed tissue, and relapse occurs later. For an elderly person with concomitant diseases and moderate contracture, the first option is often more reasonable; for an active middle-aged patient with severe deformity, the second option.

After surgery and why there are relapses

Surgery for this disease is not the final point, but the beginning of the recovery stage, and the result depends on it no less than on the work of the surgeon. The hand after surgery needs early and persistent restoration of mobility: a finger straightened on the operating table easily loses what has been achieved if the tissues heal in a flexed position. Therefore, the program includes exercises and often a night splint that holds the finger in an extended position.

1. Первые дни — возвышенное положение кисти, обезболивание, перевязки, начало осторожных движений пальцами.
2. Со второй недели — активная разработка разгибания и сгибания под контролем специалиста по реабилитации кисти.
3. Ночная шина, удерживающая палец разогнутым, — на срок, который определяет врач.
4. Работа с отёком и с рубцом: массаж рубца, силиконовые накладки после полного заживления.
5. Возвращение к лёгкой бытовой активности обычно в течение 2–4 недель, к физической работе — через 6–12 недель.
6. Наблюдение у хирурга кисти с оценкой второй руки — она вовлекается очень часто.