What is the difference between a Dupuytren’s nodule and Dupuytren’s cord?

Which is worse if you have Dupuytrens, cords or lumps?  

Dupuytren’s contracture, sometimes called Morbus Dupuytren (MD), is a benign (non-lethal) process in which excessive collagen causes the connective tissue (fascia) to thicken in the palm of the hand; this is later followed by shortening of that same tissue.   As Dupuytren contracture continues, the tissue alters appearance and normal hand function is reduced.   The progression of the problem is fairly straightforward and clear, but the causes and reasons for the various cellular changes involved in the thickening and shortening remain unknown.

There are two well known physical elements of Dupuytren’s contracture.  First, is the appearance of one or more nodules or lumps on the palm of the hand; the palm is sometimes dimpled or puckered over the nodule.  The other is the development of a tight cord-like structure under the skin of the palm.  It has been proposed in recent years that as Dupuytren contracture progresses the various cells and tissue elements of the early nodule convert into the later cords.

Natural treatment of Dupuytren’s contracture

Surgery is not always necessary to remove these palm lumps and cords. Since 2002 the Dupuytren Contracture Institute has worked with people from around the world to use natural Alternative Medicine methods instead of a hand operation.  While surgery is always an option if a brief trial of natural methods is unsuccessful, most people prefer to first use non-surgical treatment to possibly avoid the inherent risks of surgery.

>> Dupuytren Contracture Treatment – FAQs

>> Testimonials from Dupuytren Contracture Institute


Dupuytren nodule, lump or bump

One or more lumps or nodules are usually noticed when they are rather small and soft, and not firm and solid feeling as they will become later.  Often the nodule is located in the flexible area of the skin in the vicinity of the diagonal crease at the base joints of the fingers.  When a nodule appears in the lower palm, further down towards the wrist, involving a structure known as the palmar aponeurosis, it typically is less likely to become contracted and lead to reduced hand function and forced bending of the involved finger.

One or more lumps or nodules are usually noticed when they are rather small and soft, and not firm and solid feeling as they will become later.  Often the nodule is located in the flexible area of the skin in the vicinity of the diagonal crease at the base joints of the fingers.

In most cases the nodule will appear at the base of the ring (4th) and/or little (5th) finger, although the middle (3rd) and index (2nd) finger are occasionally affected, while the thumb is rarely affected.  A Dupuytren bump or nodule can also appear throughout the palm, sometimes in the digits, and in rare cases elsewhere.  When a nodule appears in the lower palm, further down towards the wrist, involving a structure known as the palmar aponeurosis, it typically is less likely to become contracted, or lead to reduced hand function and forced bending of the involved finger.

Pitting and dimpling of the palm of the skin near or within the nodule can also develop during the early phase of disease progression when the lump changes the way underlying fascia connects to the skin.

These Dupuytren bumps or lumps are usually painless, especially during the later phases of the disease progression.  When pain does occur later it is because a lump or nodule presses or rubs against a nearby tendon. As the disease progresses and finger contractures begin, the nodules tend to reduce or disappear.

Dupuytren nodules or lumps are frequently mistaken for calluses because of their location on the palm near other calluses, as well as appearance, general density and adherence to the skin like a callus.

Dupuytren cord

As Dupuytren’s contracture slowly progresses and nodule progression goes from small and soft to large and hard, the next stage is the development of long thin bands of collagen tissue located near and parallel to tendons.  These tough rope-like structures, made of collagen connective tissue, are referred to as Dupuytren cords.

They start out from the pre-tendious bands that are extensions of the normal palmar fascia and eventually thicken over time as the disease progresses. For this reason the Dupuytren cord will develop parallel and near to the tendons of the hand and fingers.

Typically the tissue changes of Dupuytren’s disease tend to stabilize temporarily at some variable mid-point; for some people this can occur within a few months or even years after onset, and remain inactive for months or many years, typically 5-6 years.

Sooner or later at around this 5-6 year point additional nodule or cord growth development starts again at a variable speed and finger contracture worsens.  This is about the time during Dupuytren’s disease that patients become serious about treatment. Eventually as the palmar tissues continue to thicken and shorten, the tendency increases for these structures to pull the involved fingers down or flex toward the palm.   Over time, as the finger remains flex toward the palm, the muscles that straighten or extend the fingers become progressively weakened and eventually undergo atrophy.  The overall effect is a hand that is progressively held in a flexed position.

Common daily tasks become increasingly more difficult to perform as the range of finger movement decreases and the degree of contracture increases.  Dressing, bathing, toilet,  operating an automobile, amongst other many other activities of daily living, are adversely impacted to a degree equal to the numbers of fingers affected by a Dupuytren nodule or cord, and the degree of fingers held in flexion.

Is this lump in my palm anything to worry about?

Lump on palm of hand should be investigated

As a general rule, anytime you discover something new happening to your body you should be concerned enough to quickly determine if the new situation has important short- and long-term consequences.   In the case of a bump, nodule or lump on the palm of the hand that appears without reason, it could be important and should not be dismissed.

Of course, the first explanation for a palm lump or nodule is that it could be a simple callus.  If a callus makes sense based on new or greater manual work you have been doing recently, especially without the protection of gloves, then that is probably all the concern that is necessary.

However, if you have not been using your hands more than usual lately, then you should do a quick mental inventory of any other recent symptoms you have noted about your hand:

  • Can’t extend or straighten one or more fingers
  • Can’t open hand completely
  • Can’t lay palm flat down on a table top
  • Fingers won’t open up after being used
  • Fingers won’t straighten
  • Fingers are restricted in full movement
  • Fingers curling in toward palm
  • Pinky finger or ring finger won’t extend fully
  • Lump, bump or nodule on the palm of the hand
  • Can’t open hands without pain
  • Stinging or burning pain in hand
  • Feels like a swollen tendon in the palm of hand
  • Feels like hand constricting and won’t open easily

If you note one or more symptoms that reduce your ability to use your hand and fingers, then you could have a fairly common condition known as Dupuytren contracture.

Lump in palm of hand common Dupuytren contracture finding

Dupuytren contracture is a problem of the soft tissue characterized by thickening and shortening of fibrous bands located in the deep tissue of the palm of the hand (palmar fascia), caused by an excess amount of a tissue protein called collagen.  As this progresses a cord of tissue will develop below the surface or a lump in the palm on the surface, resulting in reduced mobility and contracture of the hand and finger.  This involvement can affect one or both hands, and a variable number of fingers.  Dupuytren contracture presents in a wide variation, from a mild and slowly progressing contracture of a single finger, to severe and rapidly progressive involvement of several fingers of both hands, or many variations in between.

Alternative medicine treatment when combined into an aggressive assembly of natural therapies (vitamin E, PABA, acetyl-L-carnitine, massage, stretching, copper peptides, systemic enzymes, etc.) are often effective in reducing or eliminating the excess collagen cord or nodule formation and the subsequent finger contracture that so often prevents the 4th and 5th finger from being able to extend or open fully and keeps the involved fingers curled in toward the palm.   For information about using natural treatment methods to treat Dupuytren’s contracture, and to possibly avoid the need for Dupuytren release surgery, click natural Dupuytren Treatment Plan.

One or more dimpled and thickened bumps on the palm are most often caused by Dupuytren’s contracture.  This is especially true for any unusual small nodule or lump on the hand that appears on the palm at the base of the 4th (ring) or 5th (pinky) fingers, especially if the involved finger or fingers won’t completely straighten out.  Although it is always advisable to get a medical diagnosis of this kind of health problem, it is possible to develop a strong suspicion the problem is Dupuytren disease if several indicators and factors are present in your history:

  • Ancestors who came from England, Ireland, Scotland, Wales, or a Scandinavian country
  • One or more family members also have Dupuytren contracture
  • Palm lump located immediately at the base of the ring and/or pinky finger
  • Age 45 plus
  • Male
  • History of manual labor doing heavy or repetitive work, often with hands unprotected
  • History of tobacco smoking
  • Diabetes
  • Alcohol abuse or liver disease
  • Epilepsy

Dupuytren contracture will often return or recur within a few years after surgery that releases the finger contracture by removing the cords or lumps on the palm.  In fact, some forms of Dupuytren surgery have am 80% recurrence rate 3-5 years after the first operation, and even faster recurrence for a 2nd or 3rd surgery.  Hand surgery should not be seen as a solution or cure for Dupuytren’s contracture since recurrence is such a common problem not only for hand surgeons, but also the patients they serve.

Many surgeons voice the opinion that in many cases Dupuytren hand surgery seems to accelerate and worsen the development of cords and lumps on the palm.  For this reason it is suggested that a person who has Dupuytren cords and lumps should first attempt a therapeutic trial of aggressive Alternative Medicine to determine if the body is capable of reversing or even eliminating the tissue changes that makes the fingers curl in toward the palm and prevents the hand from opening completely. If after two or three months of natural treatment no change is seen, Dupuytren surgery can always be done at a later time.

Natural alternative therapies such as suggested by the Dupuytren Contracture Institute do not receive evidence-based research because of their limited profit potential and easy access by laypeople, and so have little support from the medical profession.  Even so, with a little independent research on this website it should be obvious that these natural healing ideas make sense and do not interfere with subsequent medical treatment.

 

If it is not Dupuytren contracture what else could keep my finger bent down?

Dupuytren Contracture and Similar Conditions

There are actually only a few different conditions that might be confused with Dupuytren contracture.

These are the primary hand conditions, other than Dupuytren contracture, that can prevent the finger from straightening out from a flexed position:

  1. Trigger finger – this is the sticking and sudden release of restricted flexor tendon in the sheath that also commonly as an associated aspect of  Dupuytren’s contracture
  2. Ulnar nerve injury – results in a “claw hand deformity” of the entire, due to lack of extensor muscle function
  3. Extensor tendon rupture – often associated with direct trauma or arthritis
  4. Subluxation or slipping of  extensor tendons between the knuckles associated with arthritis
  5. Ganglion cyst, or a soft-tissue mass – often presents as a small and movable nodule that is tender to palpation at the metacarpophalangeal (MCP) joint, and not as far back into the palm as Dupuytren usually is located; often seen in people younger than 50 years of age and without common risk factors for Dupuytren disease
  6. Post-traumatic or arthritic joint stiffness
  7. Sarcoma – biopsy will most likely reveal a benign etiology (e.g., lipoma, inclusion cyst).

>> Testimonials from Dupuytren Contracture Institute

>> Dupuytren surgery

The major differentiation sign between these listed conditions and Dupuytren contracture is that none of them is associated with the appearance of nodule or cord development on the palmar surface of the hand.  Based on this single point of differentiation the diagnosis of Dupuytren contracture is a fairly simple and straight forward matter.  However the diagnosis can be made more complex when the person with Dupuytren contracture also has present at the same time one or more of these other conditions.

Making the differentiation between Dupuytren contracture and other hand problems easier, the following points should be kept in mind:

  1. Typically the person with Dupuytren  disease is 50 years or older
  2. The likelihood of Dupuytren disease increases when a pitting or indentation is observed over the nodule(s) or alongside the cord(s)
  3. The likelihood of Dupuytren disease increases further when the nodule or cord formation is present bilaterally.

Early treatment of a Dupuytren contracture makes for a better outcome.  Learn more about using Alternative Medicine for Dupuytren treatment on the DCI website.

>> How to start Dupuytren treatment with Alternative Medicine

>> Dupuytren Contracture Treatment – FAQs

What is Ledderhose disease (Plantar Fibromatosis, Morbus Ledderhose)?

Ledderhose disease treatment ideas similar to Dupuytren and Peyronie treatment

Ledderhose disease is a problem of the sole of the foot at the arch, known by several different names: Ledderhose’s disease (LD), Morbus Ledderhose, and plantar fibroma.   This condition was first described in 1897 by the German surgeon Georg Ledderhose, for whom it is named.  Regardless of what it is called, the technical description of the actual tissue pathology is a plantar fibromatosis, just like Dupuytren’s contracture and Peyronie’s disease.  Ledderhose disease occurs less frequently than Dupuytren contracture, but usually in combination with it and less so does it appear with Peyronie’s disease.

Because there is similarity with many aspects of Ledderhose disease and Dupuytren contracture and Peyronie’s disease, anyone with plantar fibromatosis or Ledderhose disease who wishes to avoid surgery, and the probability of recurrence of the problem after surgery, should consider using Alternative Medicine methods to increase the ability of the body to eliminate these plantar nodules or lumps on the bottom of the feet.   Simply go to either the Dupuytren Contracture Institute or the Peyronie’s Disease Institute websites for natural treatment information.

Fibroma is a medical term that means a non-cancerous growth or tumor composed of fibrous or connective tissue elements.

Fibromatosis is a term that describes a non-cancerous soft tissue swelling or mass that contains a large group of well developed and distinct tissue cells known as fibroblasts and collagen protein, a tendency to aggressively infiltrate normal healthy tissue and to recur within the same local area.  The fibromatosis mass of Ledderhose disease usually takes the form of one or more nodules or lumps appearing the superficial layers of the tissue on the bottom of the foot near the highest point of the arch, but occasionally can also present as a cord – just as in Dupuytren contracture, but not as often.

Ledderhose disease characteristics

The Ledderhose nodules are usually painless; as they enlarge they can cause considerable pain when pressure or rubbing is applied as when walking or standing.  Size of these nodules range from 0.5 to 3.0 cm.  The skin overlying the Ledderhose nodules tend to be moved laterally with ease, at least during the early stages of the problem.  Over time, as the condition progresses and as the nodules enlarge they are able to apply pressure to blood vessels and nerves of the foot, causing even greater pain with less walking or standing.

Both feet are involved about 20%–50% of the time, and when involvement is bilateral the extent of involvement is seldom the same in both feet.

Because Ledderhose disease likely has the same or similar genetic cause as Dupuytren’s contracture, and is thought to also be triggered the same by trauma, liver and lung disease, diabetes or chronic alcohol consumption, and stressful work that involves that part of the body.  And just like Dupuytren contracture, Ledderhose disease predominantly appears primarily in men (10:1) during the fifth decade and beyond.  Of four people with Dupuytren contracture, one will also have Ledderhose disease. Unlike Dupuytren’s contracture which affects the hands and causes progressive flexion of the involved fingers toward the palm, Ledderhose disease seldom causes flexion deformity of the toes.  As another point of differentiation, the nodules of Ledderhose are larger than in Dupuytren contracture.   Just as with Dupuytren contracture, recurrence of the lesion of Ledderhose disease is high at 50-75% five years after surgery to remove the fibrous nodules and plantar aponeurosis thickened tissue.

The absence of contracture of the toes in Ledderhose disease is explained by the way the foot is typically used on an almost constant basis to walk, stand and climb stairs; all requiring frequent and repetitive stretching of the plantar (bottom of foot) soft tissue.

 

Can Dupuytren contracture recur after I have hand surgery?

Recurrence of Dupuytren contracture is common and impossible to predict

In general, Dupuytren contracture recurrence means that is spite of hand surgery, the shortened, thickened tissue appears to return to the area of previous surgery, but actually is a continuation of the extension or progression of the disease into tissue previously unaffected.  Many surgeons openly speculate that Dupuytren contracture surgery accelerates the rate and extent of the disease progression.

In broad terms, the rate of Dupuytren’s recurrence after needle aponeurotomy (palmar fasciotomy) is considerably higher than for traditional open hand surgery (palmar fasciectomy).

Avoid surgery if possible with natural Dupuytren treatment

Any type of hand surgery done to release the contractures of Dupuytren disease can eventually result in the return of more contractures.  This recurrence if followed by another hand surgery can result in the return of more contractures eventually.  While this cycle of surgery and reappearance of more contractures proceeds, the patient is exposed to the potential risks of hand surgery each time it is done: permanent numbness, reduced finger movement, reduced hand strength, reduced sensations and pain.

To avoid this cycle the patient should consider the use of a brief therapeutic trial of Alternative Medicine as a conservative and essentially risk free option that could make surgery unnecessary.

Dupuytren’s surgery, even when done well, can have bad unintended consequences as well as stimulate the recurrence of additional nodule and cord formation in the palm.  Since 2002 this website has suggested that anyone with Dupuytren contracture should first consider conservative treatment options before attempting irreversible surgery.  To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment

What is Dupuytren contracture recurrence?

The wide range of recurrence rates represent only gross estimates because there is no formally accepted definition of this term, so what characterizes a reappearance of Dupuytren contracture varies from one study or doctor to the next.  Recurrence of Dupuytren contracture can be:

  1. A finger or hand that received a prior Dupuytren surgery had to be operated on again for any one of a variety of reasons.
  2. The condition of a finger or hand worsened after hand surgery, without evidence of even initial improvement.  Sometimes the worsening is determined to be any degree of flexion deformity greater than prior to surgery, and sometimes must be a 5-10 degree increase.
  3. The condition of a finger or hand was initially good after Dupuytren surgery, but after time some degree of finger flexion returned to that finger or hand.  Sometimes the return is determined to be any degree of flexion deformity greater than the level of correction initially provided after surgery and sometimes it must be a 20-30 degree increase greater than the level of correction initially provided after surgery.

“The greatest French surgeon of the 19th century,” Guillaume Dupuytren, battled with the problem of reappearance of this disease after surgery. He experimented with a variety of tactics and methods to minimize the return but none were totally successful, just as it is today.

How often does Dupuytren contracture come back after hand surgery?

The general consensus is that after having conservative surgery by needle aponeurotomy, 50% of patients see a return of the same or worse contracture just three years later.  But after having more invasive open hand Dupuytren surgery, 50% of patients will notice a reappearance of the same or worse contracture five years later.  It seems that Dupuytren contracture will tend to come back over time to the same 50% group, but for needle aponeurotomy patients it happens much sooner.

In 2011 the partial fasciectomy is still the most common surgery for Dupuytren contracture.  In this operation the diseased tissue is completely removed and perhaps parts of the palmar aponeurosis might also be excised.  In 1990 McGrouther reported after this kind of surgery anywhere from 2 to 63% of surgery patients will have their Dupuytren tissue changes  reappear, while in 2007 Schwartz reported 44% recurrence after these same surgeries.

MedScape News Today reported in February of 2011 that contracture recurrence rates range from 27% to 80% after palmar fasciectomy (open hand surgery), and are highest  when this technique is used on  the PIP joints of the fingers. This same Medscape commentary reported 65% to 85% contracture problems recur after palmar fasciotomy (needle aponeurotomy).

Little information for laypeople about Dupuytrens returning after hand surgery

Many patients research on the web or elsewhere for information about Dupuytren contracture surgery.  Usually they find little information explaining that the palmar nodes and cords often   reappear a few years, sometimes as soon as one year, after surgery.  While attempting to learn about Dupuytren surgery from a medical website – and recurrence in particular – the reader will often encounter only a single sentence that mentions the word “return” or “recurrence,” with rarely any discussion or statistics to explain the scope or frequency of the problem.  A large medical website promoting palmar fasciectomy or needle aponeurotomy might only comment, “After surgery, a therapy program of massage, wound care, exercises and night time splinting is important to get the best possible result and prevent recurrence.”

While it can be said that such a website does inform people about the possible return of Dupuytren contracture after surgery, the usual mention is so vague and casually presented that a potential surgical patient will not understand the rather high rate at which the nodules and cords come back after being surgically removed.  With limited information being the norm it is difficult for anyone to develop a clear understanding of how often, how quickly, and how problematic is this return of the Dupuytren’s contracture problem after undergoing a surgical release of the constricted fingers.

It is almost as though the popular medical information sources are reluctant to reveal that while Dupuytren surgery can improve the palm and finger contractures for the short term, the results are somewhat temporary and have no beneficial effect on the eventual progression of the disease.

This would explain why over the years the majority of people I encounter through the Dupuytren Contracture Institute are completely surprised and unprepared when they have a reappearance of their hand contractures after surgery; most thought that once they had the  hand operation their problem was solved and would not come back again.  Over and over I learn these people were not told about Dupuytren’s recurrence by their surgeon, or that the idea of needing a second operation was presented as a genuine rarity.  It is a serious problem when patients cannot provide informed consent for their hand surgery because they have not been given adequate information about the post-surgical return of Dupuytren nodules and cords.

Final comment, Dupuytren reappearance after hand surgery

In 1964 Weckesser stated. “In general, the longer the follow-up period [after Dupuytren’s disease surgery], the lower the percentage of good results.”  This means, of course, that surgery for Dupuytren’s contracture does not stop the disease process or prevent its return, but only provides a temporary break from the contractures. This would not be too bad if the time between surgeries was longer or if side effects, or complications from surgery did not make the problem worse for some patients over time.

Better to avoid the first hand surgery if possible.

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