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For further information, see CMDT Part 41-04: Upper Extremity Musculoskeletal Injuries

Key Features

Essentials of Diagnosis

  • Benign fibrosing disorder of the palmar fascia

  • Contracture of one or more fingers can lead to limited hand function

General Considerations

  • Cause is unknown

  • Occurs primarily in white men older than 50 years. The incidence is higher among alcoholics and patients with chronic systemic disorders (especially cirrhosis)

  • Also associated with systemic fibrosing syndrome, which includes

    • Plantar fibromatosis (10% of patients)

    • Peyronie disease (1–2%)

    • Mediastinal and retroperitoneal fibrosis

    • Riedel struma

Clinical Findings

  • Onset may be acute, but slowly progressive chronic disease is more common

  • Nodular or cord-like thickening of one or both hands, with the fourth and fifth fingers most commonly affected

  • Tightness of the involved digits, with inability to satisfactorily extend the fingers; on occasion, there is tenderness

  • The contracture is well tolerated because it exaggerates the normal position of function of the hand, although resulting cosmetic problems may be unappealing

Diagnosis

  • Clinical

Treatment

  • Common treatment options

    • Corticosteroid injections

    • Percutaneous needle aponeurotomy

    • Collagenase Clostridium histolyticum injections

    • Open fasciectomy

  • Injections of triamcinolone or collagenase into a rapidly growing palmar nodule may be of benefit

  • Injection of collagenase C histolyticum lyses collagen, thereby disrupting the contracted cords

  • Surgical options for patients with more severe flexion contractures include

    • Open fasciectomy

    • Partial fasciectomy

    • Percutaneous needle aponeurotomy

Outcomes

Prognosis

  • Splinting after surgery is beneficial

  • Recurrence and more adverse events are more likely to occur after surgery than with nonoperative treatments

  • Overall, treatment success is lower for PIP joints than for MCP joints

  • Fascietomies are more successful for severe conditions involving multiple fingers, while percutaneous needle aponeurotomy is cost-effective and useful for milder cases and for single digit involvement

  • Collagenase Clostridium histolyticum injections are not currently cost effective due to high reintervention rates, regardless of severity

  • Compared to placebo, tamoxifen therapy produced moderate evidence of improvement before or after a fasciectomy

When to Refer

  • Referral can be considered when one or more digits are affected by severe contractures, which interfere with everyday activities and result in functional limitations

References

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Huisstede  BM  et al. Effectiveness of conservative, surgical, and postsurgical interventions for trigger finger, Dupuytren disease, and De Quervain disease: a systematic review. Arch Phys Med Rehabil. 2018 Aug;99(8):1635–49.
[PubMed: 28860097]
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Leafblad  ND  et al. Outcomes and direct costs of needle aponeurotomy, collagenase injection, and fasciectomy in the treatment of Dupuytren contracture. J Hand Surg Am. 2019;44:919.
[PubMed: 31537401]  
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Sanjuan-Cervero  R. Current role of the collagenase Clostridium histolyticum in Dupuytren's disease treatment. Ir J Med ...

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