- Clinical science
Dupuytren's 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 metacarpophalengeal (MCP) and proximal interphalengeal (PIP) joints. Patients with Dupuytren's contracture may also have fibroproliferative disorders at other sites (e.g., plantar fibromatosis and Peyronie's 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 10% of patients. Regardless of the treatment options, recurrence rates are high (∼ 60%).
- The exact etiology is unknown
- Genetic predisposition
- Risk factors: these factors may cause ischemic injury of the palmar fascia with subsequent development of Dupuytren contracture in genetically predisposed individuals
- Dupuytren contracture (palmar fibromatosis) is a fibroproliferative disorder of the palmar fascia
- Injury (trauma/ischemia) to the palmar fascia → triggers myofibroblasts → fibroblast proliferation and collagen (type III) deposition → thickening of the palmar fascia; → formation of nodules in the palmar fascia
- The nodules are adherent to the overlying dermis → characteristic puckering of palmar skin
- Nodules progress to form cords in the palmar fascia → flexion contractures of the palmar fascia
- The 4th and 5th fingers are most commonly involved
- Skin puckering near the proximal flexor crease: earliest sign
- Palmar nodule
- Palmar cords
- Flexion contracture of affected finger/s
- Signs of aggressive disease: Knuckle pads (Garrod nodes) ; Plantar fibromatosis (Ledderhose disease)
- Peyronie disease
The differential diagnoses listed here are not exhaustive.
Conservative therapy: Indicated in patients with early disease (skin puckering; nodules) and no functional disability.
- Hand splint/brace
- Intralesional injections: Indicated in patients with rapidly progressing disease or painful nodules
Surgery: Indicated in patients with functional disability due to contractures
- Variable prognosis
- Recurrence rates are high, even after surgery (∼ 60%)