> Table of Contents > Dupuytren Contracture
Dupuytren Contracture
Joshua L. Eaton, MD, FAWM
Alex Nguyen, MD
image BASICS
DESCRIPTION
  • Palmar fibromatosis; caused by progressive fibrous proliferation and tightening of the fascia of the palms, resulting in flexion deformities and loss of function
  • Not the same as “trigger finger,” which is caused by thickening of the distal flexor tendon
  • Similar change rarely occurs in plantar fascia, usually appearing simultaneously.
  • System(s) affected: musculoskeletal
  • Synonyms: morbus Dupuytren; Dupuytren disease; “Celtic hand”
EPIDEMIOLOGY
Prevalence
  • Increases with age; mean prevalence in western countries: 12%, 21%, and 29% at ages 55, 65, and 75 years, respectively. Norway: 30% of males >60 years; Spain: 19% of males >60 years
  • More common in Caucasians of Scandinavian or Northern European ancestry
ETIOLOGY AND PATHOPHYSIOLOGY
Unknown; possibly a T-cell-mediated autoimmune disorder. Occurs in three stages:
  • Proliferative phase: proliferation of myofibroblasts with nodule development on palmar surface
  • Involutional stage: spread along palmar fascia to fingers with cord development
  • Residual phase: spread into fingers with cord tightening and contracture formation
Genetics
  • Autosomal dominant with incomplete penetrance:
  • Siblings with 3-fold risk
  • 68% of male relatives of affected patients develop disease at some time.
RISK FACTORS
  • Smoking (mean: 16 pack-years; odds ratio: 2.8)
  • Increasing age
  • Male/Caucasian; male > female (1.7:1)
  • Workers exposed to vibration—risk doubles if regular (weekly) exposure
  • Diabetes mellitus (increases with duration of DM, usually mild; middle and ring finger involved)
  • Epilepsy
  • Chronic illness (e.g., pulmonary tuberculosis, liver disease, HIV)
  • Hypercholesterolemia
  • Alcohol consumption
GENERAL PREVENTION
Avoid risk factors, especially if a strong family history.
COMMONLY ASSOCIATED CONDITIONS
  • Alcoholism
  • Epilepsy
  • Diabetes mellitus
  • Chronic lung disease
  • Occupational hand trauma (vibration)
  • Hypercholesterolemia
  • Carpal tunnel syndrome
  • Peyronie disease
image DIAGNOSIS
PHYSICAL EXAM
  • Painless plaques or nodules in palmar fascia
  • Cordlike band in the palmar fascia
  • Skin adheres to fascia and becomes puckered.
  • Palpable subcutaneous nodules
  • Reduced flexibility of MCP and PIP joints
  • No sign of inflammation
  • Web space contractures
  • Ectopic Dupuytren can involve plantar (Ledderhose—10%) and penile (Peyronie—2%) fascia.
    • Knuckle pads over PIP:
      • Garrod nodes associated with severe disease
    • Disease stages:
      • Early: skin pits (can also be seen in nevoid basal cell cancer and palmar keratosis)
      • Intermediate: nodules and cords. Nerves and vessels can be entwined in cords.
      • Late: contractures
DIFFERENTIAL DIAGNOSIS
  • Tendon abnormalities
  • Camptodactyly: early teens; tight fascial bands on ulnar side of small finger
  • Diabetic cheiroarthropathy: all four fingers
  • Volkmann ischemic contracture
DIAGNOSTIC TESTS & INTERPRETATION
Diagnostic Procedures/Other
MRI can assess cellularity of lesions that correlate with recurrence after surgery.
Test Interpretation
  • Myofibroblasts predominate
  • Nodules: lumps fixed to skin hypercellular masses
  • Cords: organized collagen type III arranged parallel and hypocellular
  • First stage (proliferative): increased myofibroblasts
  • Second stage (residual): dense fibroblast network
  • Third stage (involutional): Myofibroblasts disappear.
image TREATMENT
GENERAL MEASURES
  • Physiotherapy alone is ineffective:
    • Intermittent splinting is unlikely to be effective.
    • Continuous splinting may help pre- and postop.
  • Follow isolated involvement of palmar fascia conservatively.
  • MCP joint involvement can be followed conservatively if flexion contracture is <30 degrees.
MEDICATION
First Line
  • Clostridial collagenase injections (FDA-approved in 2010):
    • Degrades collagen to allow manual rupture of diseased cord
    • Best for isolated cord of MCP joint
    • 5-year recurrence rate of 47%; comparable with surgical recurrence rates (1)[B]
    • More rapid recovery of hand function compared to limited fasciectomy with fewer serious adverse events (2)[B]
    • Complications: injection site reaction, skin tear
    • Can do two cords concurrently
    • Can be effective for postsurgical recurrence
  • Steroid injection:
    • Can treat acute nodules or painful knuckle pads
    • Serial triamcinolone injections improved long-term outcomes when combined with needle aponeurotomy (3)[B].
Second Line
Surgery for contracture >30%
P.317

ISSUES-FOR-REFERRAL
  • Any involvement of PIP joints
  • MCP joints contracted >30 degrees
  • Positive Hueston tabletop test: When the palm is placed on a flat surface, the digits cannot be simultaneously placed fully on the same surface as the palm because of flexion contractures.
ADDITIONAL THERAPIES
  • Percutaneous and needle fasciotomy:
    • Best for MCP joint; improvement of 93% versus 57% for PIP joint (4)[B]
    • Recurrence common; 50%
    • Shown to be effective for recurrent disease (4)[B]
    • Better for MCP joints in patients with comorbid conditions; lower complication rate, but higher recurrence (5)[C]
  • Continuous elongation (atraumatic elongation using an external device, typically on 4th and 5th digits prepares a severely contracted joint for surgery (6)[B].
SURGERY/OTHER PROCEDURES
  • Dermofasciectomy/limited fasciectomy/segmental aponeurectomy:
    • Greater initial correction over nonincisional treatment; higher complication rates (5)[C]
    • Night extension orthosis in combination with standard hand therapy no different maintaining finger extension than hand therapy alone in the 3 months following surgical release (6)[B].
  • Indications:
    • Any involvement of the PIP joints
    • MCP joints contracted at least 30 degrees
    • Positive Hueston tabletop test
  • May require skin grafts for wound closure with severe cutaneous shrinkage
  • 80% have full range of movement with early surgery.
  • Amputation of 5th digit if severe and deforming
  • MCP joints respond better to surgery than PIP joints, especially if contracted >45 degrees.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Regular follow-up every 6 months to 1 year
PATIENT EDUCATION
  • Avoid risk factors (alcohol, vibratory exposure, etc.), especially if strong family history.
  • Mild disease: Passively stretch digits twice a day and avoid recurrent gripping of tools.
PROGNOSIS
  • Unpredictable but usually slowly progressive
  • 10% may regress spontaneously.
  • Dupuytren diathesis predicts aggressive course. Features include ethnicity (Nordic), family history, bilateral lesions outside of palm, age <50 years— all factors with 71% risk of recurrence compared to baseline 23% without any risk factors.
  • Prognosis is better for MCP versus PIP joint after surgery and collagenase injection.
REFERENCES
1. Peimer CA, Blazar P, Coleman S, et al. Dupuytren contracture recurrence following treatment with collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-year data. J Hand Surg Am. 2015;40(8):1597-1605.
2. Zhou C, Hovius SE, Slijper HP, et al. Collagenase Clostridium histolyticum versus limited fasciectomy for Dupuytren's contracture: outcomes from a multicenter propensity score matched study. Plast Reconstr Surg. 2015;136(1):87-97.
3. McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for Dupuytren disease: long-term follow-up of a randomized controlled trial. J Hand Surg Am. 2014;39(10):1942-1947.
4. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy for recurrent Dupuytren disease. J Hand Surg Am. 2012;37(9):1820-1823.
5. Henry M. Dupuytren's disease: current state of the art. Hand (N Y). 2014;9(1):1-8.
6. Collis J, Collocott S, Hing W, et al. The effect of night extension orthoses following surgical release of Dupuytren contracture: a single-center, randomized, controlled trial. J Hand Surg Am. 2013;38(7):1285.e2-1294.e2.
Additional Reading
&NA;
  • Ball C, Pratt AL, Nanchahal J. Optimal functional outcome measures for assessing treatment for Dupuytren's disease: a systematic review and recommendations for future practice. BMC Musculoskelet Disord. 2013;14:131.
  • Eaton C. Evidence-based medicine: Dupuytren contracture. Plast Reconstr Surg. 2014;133(5): 1241-1251.
  • Lanting R, Broekstra DC, Werker PM, et al. A systematic review and meta-analysis on the prevalence of Dupuytren disease in the general population of Western countries. Plast Reconstr Surg. 2014;133(3): 593-603.
  • Michou L, Lermusiaux JL, Teyssedou JP, et al. Genetics of Dupuytren's disease. Joint Bone Spine. 2012;79(1):7-12.
  • Sweet S, Blackmore S. Surgical and therapy update on the management of Dupuytren's disease. J Hand Ther. 2014;27(2):77-84.
Codes
&NA;
ICD10
M72.0 Palmar fascial fibromatosis [Dupuytren]
Clinical Pearls
&NA;
  • Dupuytren contracture is a fixed flexion deformity of (most commonly) the 4th and 5th digits due to palmar fibrosis. 90% of cases are progressive.
  • Refer patients with involvement of the PIP joints or MCP involvement with contractures of >30 degrees.
  • Both surgical and enzymatic fasciotomy have high rate of recurrence.