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Dupuytren's Contracture: Causes, Symptoms and Treatment
Dr. Joseph Woodward, an Orthopedic Surgeon at Evergreen Health Orthopedic and Sports care, joins us to discuss what Dupuytren's Disease is, what the symptoms are, and what the treatment process looks like.
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Learn more about Joseph Woodward, MD
Joseph Woodward, MD
Dr. Joseph Woodward is a fellowship-trained hand surgeon, providing care for both elective hand problems and hand trauma. During his plastic surgery residency training, he developed skills in soft tissue handling and wound management. In his orthopedic hand fellowship, he learned a variety of surgical techniques from mentors who trained with the pioneers of hand surgery.Learn more about Joseph Woodward, MD
Transcription:
Scott Webb: Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. And today, we're here with Dr. Joseph Woodward, orthopedic surgeon at EvergreenHealth Orthopedic and Sports Care to discuss Dupuytren's disease, which is recognized by noticeably bent fingers.
Dr. Woodward, welcome. Thanks for joining me. I mentioned there that Dupuytren's is recognized by noticeably bent fingers, and I know this condition can really impact people's daily lives. So as we get rolling here, what is Dupuytren's disease?
Dr. Joseph Woodward: Dupuytren's disease is a process in which normal tissue in our hands can become contracted over time. It usually progresses slowly and there's a hereditary component as well that, as time goes on and as we get older, often this disease causes fibrosis in the palms that causes the fingers to bend down, so they can't be straightened out, and that then causes functional deficits. So it can affect people across the spectrum, men and women but, usually, as we get older and mostly folks of Northern European descent.
Scott Webb: All right. Wondering if certain people are more prone to the disease? Are there certain risk factors, behavior, lifestyle? Are there things that we do to ourself or is this mostly hereditary?
Dr. Joseph Woodward: Yeah, unfortunately, there's not much we can do to change or prevent the course of Dupuytren's. It's mostly hereditary, but there is variability in how it progresses and how severe it is even within families. Some people in certain families get it more severe than others. Some people don't get it and it can skip a generation from being so severe. But there's nothing that people, obviously, do that we've been able to find out that cause it to get worse over time.
Scott Webb: Do you recommend that folks be screened or checked or diagnosed? I'm not sure what the right terminology is. In other words, is there any advantage to being diagnosed early with it in terms of treatment?
Dr. Joseph Woodward: Yeah, there is an advantage in getting to it before it gets very severe. There's no specific screening. If you know it's in your family, certainly seeing a hand surgeon, a specialist who treats Dupuytren's disease, at any point, they can give you guidance on how severe it is, whether treatment is recommended. But most commonly, this is something folks mention to their primary care physician. They notice some bumps that form in their palm. And then, their primary care physician either keeps an eye on it for a little while to see how it's progressing or refers them onto someone like me to give a little bit more information about when treatment is recommended.
Scott Webb: Yeah. When we think about treatment then, maybe you can take us through that, so if someone gets to you, makes an appointment with you because they think that they have Dupuytren's, what can they expect? What do you do in terms of diagnosis? But ultimately, what is the treatment? Is it always surgery? Is that really sort of the gold standard or are there other types of therapies before you get there?
Dr. Joseph Woodward: There's lots of different types of treatments that are employed. The gold standard is certainly surgery. The patient can expect to basically be seen by the surgeon and we discuss whether or not surgery or one of these other treatments, which I'll talk about in a second, is recommended based on how severe the contracture is. So we teach patients about what's called the tabletop test. If you can put your hand flat on a table with your palm down and there's no lift of the palm off the table, then usually we tell folks, "No rush," nothing that's got to be done right away. But as these contractures worsen and patients start to have functional issues, putting their hands in their pockets, putting gloves on, doing certain activities, like playing the piano, then we talk about whether treatment would be worthwhile.
There's several different types as I discussed. There's one treatment called needle aponeurotomy, which is where a needle is used to basically break up the cords that form in our palm. These scar tissue type cords and then straighten out the fingers. That mechanism of treatment has the quickest time to recurrence. We talk about how Dupuytren's is a disease that we manage, not cure, and that one seems to come back the fastest.
There's two that I offer most of the time and there's one that's a drug called Xiaflex, which is an injection of what's called a collagenase as these contractures are made from collagen. And it's an injection that goes into these contractures and dissolves the cords in one spot. And then, you come back for a secondary procedure to straighten the finger out. That has kind of what we call a middle time to recurrence, not as great as surgery in terms of how long it might take to come back, but better than the needle aponeurotomy we were talking about a moment ago. It's also great for folks who either surgery's not an option or they don't have any interest in surgery. It's less invasive, but does tend to come back a bit faster.
And then as I said, the gold standard is surgery, which is an outpatient surgery. You come and go the same day. You do have a little bit of rehab afterwards with some hand therapy and a splint that you wear for a few weeks to keep the fingers straight. The surgery offers, in most cases, the ability to get the fingers very straight and prevent them from contracting again for at least several years and hopefully never, but we just have to see how again the patient's disease burden is and what's involved.
Scott Webb: Yeah, I was going to ask you, is there an average length? Is it five years, 10 years, 15 years? Or does this really just vary on the patient? And maybe there's something that they can do ultimately long-term to sort of, you know, stretch that timeline out maybe just a bit?
Dr. Joseph Woodward: One thing that can happen is that you can treat one finger, but then it can come back in another finger or a neighboring finger, which requires additional treatment. But when we're talking about the same finger or the same contracture of a joint, we say surgery kind of has a five to seven-year or longer average recurrence rate, whereas the injections more on the three to five-year range, but it is variable. And we certainly see people who get treated, who nothing seems to come back in that area, but then they might get it in a different finger or on the other hand, and that progresses to need treatment separately.
Scott Webb: Yeah, right. As you say, that's really about family history and genetics and there's such a strong hereditary component to this, so you might fix one finger and then the other hand, right? So, just thinking as we wrap up here, if folks know that they have a family history, right, and there's not much they can do to prevent the onset, when do they begin to see the symptoms? When might they notice this? Is it something that, you know, kids may notice or is that also variable?
Dr. Joseph Woodward: Yeah, it's almost always exclusively adults. We don't see this in children. And it usually happens that they notice either in middle or later years some bumps in their palm called nodules. And then, you might also notice what you call a little pit where the skin seems indented, kind of stuck in the palm. And that then can progress into these cords that I was speaking about. And these cords, basically, when we remove them, they just look like scar tissue under the microscope. There's nothing unusual. It's not a tumor, it's not dangerous. And it's purely that functional contracture over time. And some people get these bumps in their palms and they go their whole lives without a contracture. And other people, the contracture comes on rapidly over six months, but it's still not, you know, overnight or anything like. But when people see these bumps in their palms, they often will mention it to their primary doctors or they might see a hand specialist and then they can get more information. And then, we usually watch it over the next several months and see what the progression and how rapid that particular person's case is progressing.
Scott Webb: Yeah, it definitely seems like the surveillance is common and maybe prudent early on. And then, ultimately, folks may get to the gold standard or get to the surgery. This has been really interesting, doctor. I host a lot of these and I get to learn a lot of stuff from a lot of experts, but this was a new one for me. So, great to pick your brain a little bit and learn more about Dupuytren's disease today. I'm sure listeners found it educational as well. So thanks so much. You stay well.
Dr. Joseph Woodward: My pleasure. Thanks for having me.
Scott Webb: And call 425-899-4810 to schedule an appointment with the collaborative hand and wrist care team at EvergreenHealth, where you'll find advanced care that fits your needs.
Please remember to subscribe, rate and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.
Scott Webb: Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. And today, we're here with Dr. Joseph Woodward, orthopedic surgeon at EvergreenHealth Orthopedic and Sports Care to discuss Dupuytren's disease, which is recognized by noticeably bent fingers.
Dr. Woodward, welcome. Thanks for joining me. I mentioned there that Dupuytren's is recognized by noticeably bent fingers, and I know this condition can really impact people's daily lives. So as we get rolling here, what is Dupuytren's disease?
Dr. Joseph Woodward: Dupuytren's disease is a process in which normal tissue in our hands can become contracted over time. It usually progresses slowly and there's a hereditary component as well that, as time goes on and as we get older, often this disease causes fibrosis in the palms that causes the fingers to bend down, so they can't be straightened out, and that then causes functional deficits. So it can affect people across the spectrum, men and women but, usually, as we get older and mostly folks of Northern European descent.
Scott Webb: All right. Wondering if certain people are more prone to the disease? Are there certain risk factors, behavior, lifestyle? Are there things that we do to ourself or is this mostly hereditary?
Dr. Joseph Woodward: Yeah, unfortunately, there's not much we can do to change or prevent the course of Dupuytren's. It's mostly hereditary, but there is variability in how it progresses and how severe it is even within families. Some people in certain families get it more severe than others. Some people don't get it and it can skip a generation from being so severe. But there's nothing that people, obviously, do that we've been able to find out that cause it to get worse over time.
Scott Webb: Do you recommend that folks be screened or checked or diagnosed? I'm not sure what the right terminology is. In other words, is there any advantage to being diagnosed early with it in terms of treatment?
Dr. Joseph Woodward: Yeah, there is an advantage in getting to it before it gets very severe. There's no specific screening. If you know it's in your family, certainly seeing a hand surgeon, a specialist who treats Dupuytren's disease, at any point, they can give you guidance on how severe it is, whether treatment is recommended. But most commonly, this is something folks mention to their primary care physician. They notice some bumps that form in their palm. And then, their primary care physician either keeps an eye on it for a little while to see how it's progressing or refers them onto someone like me to give a little bit more information about when treatment is recommended.
Scott Webb: Yeah. When we think about treatment then, maybe you can take us through that, so if someone gets to you, makes an appointment with you because they think that they have Dupuytren's, what can they expect? What do you do in terms of diagnosis? But ultimately, what is the treatment? Is it always surgery? Is that really sort of the gold standard or are there other types of therapies before you get there?
Dr. Joseph Woodward: There's lots of different types of treatments that are employed. The gold standard is certainly surgery. The patient can expect to basically be seen by the surgeon and we discuss whether or not surgery or one of these other treatments, which I'll talk about in a second, is recommended based on how severe the contracture is. So we teach patients about what's called the tabletop test. If you can put your hand flat on a table with your palm down and there's no lift of the palm off the table, then usually we tell folks, "No rush," nothing that's got to be done right away. But as these contractures worsen and patients start to have functional issues, putting their hands in their pockets, putting gloves on, doing certain activities, like playing the piano, then we talk about whether treatment would be worthwhile.
There's several different types as I discussed. There's one treatment called needle aponeurotomy, which is where a needle is used to basically break up the cords that form in our palm. These scar tissue type cords and then straighten out the fingers. That mechanism of treatment has the quickest time to recurrence. We talk about how Dupuytren's is a disease that we manage, not cure, and that one seems to come back the fastest.
There's two that I offer most of the time and there's one that's a drug called Xiaflex, which is an injection of what's called a collagenase as these contractures are made from collagen. And it's an injection that goes into these contractures and dissolves the cords in one spot. And then, you come back for a secondary procedure to straighten the finger out. That has kind of what we call a middle time to recurrence, not as great as surgery in terms of how long it might take to come back, but better than the needle aponeurotomy we were talking about a moment ago. It's also great for folks who either surgery's not an option or they don't have any interest in surgery. It's less invasive, but does tend to come back a bit faster.
And then as I said, the gold standard is surgery, which is an outpatient surgery. You come and go the same day. You do have a little bit of rehab afterwards with some hand therapy and a splint that you wear for a few weeks to keep the fingers straight. The surgery offers, in most cases, the ability to get the fingers very straight and prevent them from contracting again for at least several years and hopefully never, but we just have to see how again the patient's disease burden is and what's involved.
Scott Webb: Yeah, I was going to ask you, is there an average length? Is it five years, 10 years, 15 years? Or does this really just vary on the patient? And maybe there's something that they can do ultimately long-term to sort of, you know, stretch that timeline out maybe just a bit?
Dr. Joseph Woodward: One thing that can happen is that you can treat one finger, but then it can come back in another finger or a neighboring finger, which requires additional treatment. But when we're talking about the same finger or the same contracture of a joint, we say surgery kind of has a five to seven-year or longer average recurrence rate, whereas the injections more on the three to five-year range, but it is variable. And we certainly see people who get treated, who nothing seems to come back in that area, but then they might get it in a different finger or on the other hand, and that progresses to need treatment separately.
Scott Webb: Yeah, right. As you say, that's really about family history and genetics and there's such a strong hereditary component to this, so you might fix one finger and then the other hand, right? So, just thinking as we wrap up here, if folks know that they have a family history, right, and there's not much they can do to prevent the onset, when do they begin to see the symptoms? When might they notice this? Is it something that, you know, kids may notice or is that also variable?
Dr. Joseph Woodward: Yeah, it's almost always exclusively adults. We don't see this in children. And it usually happens that they notice either in middle or later years some bumps in their palm called nodules. And then, you might also notice what you call a little pit where the skin seems indented, kind of stuck in the palm. And that then can progress into these cords that I was speaking about. And these cords, basically, when we remove them, they just look like scar tissue under the microscope. There's nothing unusual. It's not a tumor, it's not dangerous. And it's purely that functional contracture over time. And some people get these bumps in their palms and they go their whole lives without a contracture. And other people, the contracture comes on rapidly over six months, but it's still not, you know, overnight or anything like. But when people see these bumps in their palms, they often will mention it to their primary doctors or they might see a hand specialist and then they can get more information. And then, we usually watch it over the next several months and see what the progression and how rapid that particular person's case is progressing.
Scott Webb: Yeah, it definitely seems like the surveillance is common and maybe prudent early on. And then, ultimately, folks may get to the gold standard or get to the surgery. This has been really interesting, doctor. I host a lot of these and I get to learn a lot of stuff from a lot of experts, but this was a new one for me. So, great to pick your brain a little bit and learn more about Dupuytren's disease today. I'm sure listeners found it educational as well. So thanks so much. You stay well.
Dr. Joseph Woodward: My pleasure. Thanks for having me.
Scott Webb: And call 425-899-4810 to schedule an appointment with the collaborative hand and wrist care team at EvergreenHealth, where you'll find advanced care that fits your needs.
Please remember to subscribe, rate and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.