Dupuytren Contracture

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