Dupuytren contracture is progressive contracture of the palmar fascial bands, causing flexion deformities of the fingers. Treatment is with corticosteroid injection, surgery, or injections of clostridial collagenase.
(See also Overview and Evaluation of Hand Disorders.)
Dupuytren contracture is one of the more common hand deformities; the incidence is higher among men and increases after age 45 (1). This autosomal dominant condition with variable penetrance may occur more commonly among patients with diabetes, alcohol use disorder, or epilepsy. However, the specific factors that cause the palmar fascia to thicken and contract are unknown.
Reference
1. Geoghegan JM, Forbes J, Clark DI, Smith C, Hubbard R: Dupuytren's disease risk factors. J Hand Surg Br. 2004;29(5):423-426. doi:10.1016/j.jhsb.2004.06.006
Symptoms and Signs of Dupuytren Contracture
DR P. MARAZZI/SCIENCE PHOTO LIBRARY
The earliest manifestation is usually a tender nodule in the palm, most often near the little or ring finger; it gradually becomes painless. Next, a superficial cord forms and contracts and ultimately flexes the metacarpophalangeal (MCP) joints and interphalangeal joints of the fingers. The hand eventually becomes arched. The disease is occasionally associated with fibrous thickening of the dorsum of the proximal interphalangeal (PIP) joints (Garrod pads), Peyronie disease (penile fibromatosis) in about 7 to 10% of patients, and rarely nodules on the plantar surface of the feet (plantar fibromatosis) (1).
Other types of flexion deformities of the fingers can also occur in diabetes, locked trigger fingers, an ulnar claw hand, systemic sclerosis, and complex regional pain syndrome, which need to be differentiated.
Symptoms and signs reference
1. Bogdanov I, Rowland Payne C: Dupuytren contracture as a sign of systemic disease. Clin Dermatol. 2019; 37(6):675-678. doi:10.1016/j.clindermatol.2019.07.027
Diagnosis of Dupuytren Contracture
Clinical evaluation
Dupuytren contracture is diagnosed primarily based on the clinical history and physical examination. The hallmark finding on physical examination early on is a puckering of the skin overlying the flexor tendon just proximal to the flexor crease of the finger on the palm, usually of the fourth or fifth finger. These findings typically progress and may develop into palpable nodules, skin tethering, and flexion contractures of the affected fingers. Imaging of the hand is generally not necessary.
Treatment of Dupuytren Contracture
Corticosteroid injection (before contractures develop)
Surgery for disabling contractures, including percutaneous needle fasciotomy
Injection of a corticosteroid suspension into the nodule may relieve local tenderness if begun before contractures develop. However, this tenderness is self-limiting and often resolves with no intervention.
If the hand cannot be placed flat on a table or, especially, when significant contracture develops at the proximal interphalangeal (PIP) joints, surgery is usually indicated. Surgical options include percutaneous needle fasciotomy, temporary application of a dynamic external fixator for PIP joint contractures, and open palmar/digital fasciectomy. For severe disease with multiple finger involvement, open surgery with excision of the diseased fascia is the best treatment; excision must be meticulous because the tissue surrounds neurovascular bundles and tendons. Incomplete excision or new disease results in recurrent contracture, especially in patients who are young at disease onset or who have a family history, Garrod pads, Peyronie disease, or plantar foot involvement.
1, 2), particularly those at the MCP joint. Collagenase injections and surgical fasciectomy result in similar improvements at the MCP joint, but injections lead to more rapid recovery with fewer early complications (3). However, when comparing midterm results (2 to 5 years after treatment) of collagenase injection, percutaneous needle fasciotomy, and surgical fasciectomy, injections had the highest recurrence rate requiring reintervention, whereas surgery had the lowest rate of recurrent contractures (4).
Treatment references
1. Hurst LC, Badalamente MA, Hentz VR, et al: Injectable collagenaseClostridium histolyticum for Dupuytren's contracture. N Engl J Med 361(10):968–979, 2009. doi: 10.1056/NEJMoa0810866.
2. Witthaut J, Jones G, Skrepnik N, et al: Efficacy and safety of collagenaseClostridium histolyticum injection for Dupuytren contracture: Short-term results from 2 open-label studies. J Hand Surg Am 38(1):2–11, 2013. doi: 10.1016/j.jhsa.2012.10.008.
3. Zhou C, Hovius SE, Slijper HP, et al: CollagenaseClostridium histolyticum versus limited fasciectomy for Dupuytren's contracture: Outcomes from a multicenter propensity score matched study. Plast Reconstr Surg 136(1):87–97, 2015. doi: 10.1097/PRS.0000000000001320.
4. Leafblad ND, Wagner E, Wanderman NR, et al: Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture. J Hand Surg Am. 2019; 44(11):919-927. doi:10.1016/j.jhsa.2019.07.017
