What is Dupuytren’s Contracture?
Dupuytren's contracture is a fairly common condition that causes one or more fingers to bend into the palm of the hand. The condition often occurs in later life, and is most common in men who are aged over 40. Around one in six men over the age of 65 are affected in the UK.
The symptoms of Dupuytren's contracture are often mild and painless and do not require treatment. The condition most often starts with a small, hard lump or nodule in the skin of the palm and may stay the same for months or years. The lump sometimes feels tender to begin with, but this usually passes with time. More lumps may then develop. The lumps are non-cancerous (benign) and the condition isn't life-threatening for those who develop it, although it can be a nuisance to live with.
Over time, the lumps can extend and form cords of tissue. These cords can shorten (contract) and, if the cords run along a finger or thumb, they can pull it, so it becomes bent towards the palm. These contractures are often mild and painless, but they can get steadily worse over time.
Patients should be aware that up to 40% of people will have a recurrence following surgery: this means Dupuytren’s contracture can return to the same spot on the hand or may reappear somewhere else. Recurrence is more likely in younger patients; or if the original contracture was severe; or if there is a strong family history of the condition.
Many cases of Dupuytren's contracture are mild and don't need treatment. Treatment may be helpful if the condition is interfering with the normal functioning of your hand.
In July 2017 the National Institute for Health and Care Excellence (NICE) published guidance on the most appropriate treatments available for Dupuytren’s contracture and when these treatments should be used.
There are two types of treatment currently recommended by NICE for Dupuytren's contracture:
- Injections with a medication called collagenase clostridium histolyticum (CCH)
- Surgery with a fasciectomy or fasciotomy, where the surgeon will make an incision in the skin of your hand, so they can gain access to the connective tissue underneath. They'll then cut the thickened connective tissue to divide it up or remove the thickened tissue completely, allowing you to straighten your fingers. However, surgery for Dupuytren's contracture can't always fully straighten the affected finger or thumb, and the contracture can recur after surgery. If a contracture does recur, further surgery may be possible.
Patient eligibility criteria
Patients requiring treatment, either collagenase injection or surgery, must meet the following clinical criteria:
- Evidence of at least moderate disease OR first web contracture
- For patients where treatment with collagenase injections is the most clinically appropriate treatment, one injection should be given per treatment session, in an outpatient setting, the injection should be performed by a suitably qualified clinician.
Your Right of Patient Choice and Shared Decision Making
- The choice of treatment (injection with collagenase or surgery) is made on an individual basis after discussion between the responsible hand surgeon and the patient about the risks and benefits of the treatments available.
This means for patients who DO NOT meet the specified criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.
For the purposes of this guidance the baseline for moderate disease is classified as:
- Functional problems AND
- Moderate metacarpo-phalangeal joint contracture (at least 30 degrees) OR
- Any proximal inter-phalangeal joint contracture OR
- First web contracture.
Advice and guidance
- For more information, search for ‘Dupuytren's contracture' at www.nhs.uk
- Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
Treatment policy for patients covered by NHS Birmingham and Solihull CCG