• Clinical science

Dupuytren contracture

Summary

Dupuytren contracture is a common fibroproliferative disorder affecting the palmar fascia mainly of the 4th and 5th fingers, particularly in males. The etiology is uncertain. Trauma (manual labor, pneumatic tools) or ischemic injury (cigarette smoking, diabetes) are thought to stimulate fibroblast proliferation and collagen deposition in the palmar fascia of genetically susceptible individuals. Skin puckering proximal to the flexor crease of the affected finger is the earliest sign. As the disease progresses, nodules and cords develop in the palmar fascia, causing flexion contractures to develop at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Patients with Dupuytren contracture may also have fibroproliferative disorders at other sites (e.g., plantar fibromatosis and Peyronie disease). Diagnosis is usually clinical but ultrasound can demonstrate the nodules and cords of the palmar fascia. Treatment depends on the severity of the disease. Observation, passive finger extension exercises, and/or splints are useful in early disease. Patients with moderately severe contractures can be treated with intralesional injections of corticosteroid or collagenase. Severe contractures are best treated with surgery (fasciectomy, fasciotomy). Prognosis is variable, with the disease remaining indolent for many years or progressing rapidly. Regression is seen in approx. 10% of patients, and recurrence rates are high (approx. 60%) regardless of treatment.

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

The exact etiology is unknown, but several factors appear to play a role in the development of the disease. [4]

Pathophysiology

Clinical features

Diagnostics

Differential diagnoses

Differential diagnosis of Dupuytren contracture

Condition Etiology Clinical features [11]

Palmar fasciitis

Claw hand deformity
  • Extension of the MCP with PIP and DIP flexion
  • 4th and 5th fingers affected
  • Numbness of the ulnar aspect of the palm

Stenosing tenosynovitis

(trigger finger)

  • Painful locking of a finger in flexed position; releases suddenly with a snap/pop on extension
  • A tender nodule is often palpable at the base of the metacarpophalangeal joint
  • Mostly affects thumbs and ring fingers

The differential diagnoses listed here are not exhaustive.

Treatment

  • Conservative therapy: Indicated in patients with early disease (skin puckering; nodules) and no functional disability. [4]
  • Intralesional injections: Indicated in patients with rapidly progressing disease or painful nodules [4]
  • Surgery: Indicated in patients with functional disability due to contractures [9]
  • Prognosis
    • Variable prognosis [4][9]
    • Recurrence rates are high, even after surgery (∼ 60%) [9]