Dupuytren's contracture

• Dupuytren's contracture:

  • Benign and progressive disorder of the hand
  • Development of cords within the palmar fascia leading to contraction and flexion deformity
  • Often affects the ring finger
  • Predominantly affects - middle aged men, especially those of a Scandinavian and northern European background
• Risk factors:

  • Most patients have a hereditary component - autosomal dominant
  • Excessive alcohol intake
  • Manual work - especially involving vibrational machinery
  • Smoking - 3 times more likely to develop condition
  • Diabetes - more with type 1 but also type 2
• Pathophysiology:

  • The palmar fascia of the hand forms a triangle of strong connective tissue on the palm.
  • In Dupuytren’s contracture, the fascia of the hands becomes thicker and tighter and develops nodules. Cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion and restricting their ability to extend (contracture). 
  • It is unclear why the fascia becomes thicker and tighter. However, it is thought to be an inflammatory process in response to microtrauma. 
• Presentation:

  • First sign is the development of hard nodules on the palm
  • Skin thickening and pitting
  • Fascia becomes thicker and the finger is pulled into flexion - cannot extend affected finger fully
  • A thick, nodular cord can be palpated from the palm into the affected finger
  • Usually painless
• Hueston's table top test:

  • The patient is asked to place their palms down onto a flat surface.
  • The test is positive if the patient is unable to do this and there is greater than 30 degrees of flexion at the MCP.
• The following conditions also fall under the fibromatoses category and thus may also be seen in patients with Dupuytren’s disease:

  • Plantar fibromatosis (Lederhosen disease) – affecting the sole of the foot
  • Peyronie’s disease – affecting the penis
  • Garrod disease – affecting knuckle pads
• Diagnosis:

  • Consider checking lipids, LFTs and HbA1c given the association of Dupuytren’s with hyperlipidaemia, alcoholic liver disease and diabetes.
  • Dupuytren’s is however primarily a clinical diagnosis.
• Conservative management:

  • If a patient feels their Dupuytren’s is not significantly impacting their activities of daily living, reassurance and safety netting is recommended.
• Referral to a local hand clinic is recommended for patients who are experiencing significant functional impairment and/or if they have a positive tabletop test
• Non surgical management:

  • Collagenase - enzyme therapy injected into palpable cords
  • Radiotherapy - only if early stages of disease prior to contracture
  • Corticosteroids are not recommended
• Surgical management:

  • Surgery does not stop the disease process so contractures are likely to recur
  • Needle fasciotomy - fine needle used to break up cords and nodules
  • Limited fasciectomy - segments of contracture are removed
  • Regional fasciectomy - whole cord removed
  • Dermofasciectomy - remove the abnormal fascia and cord, as well as associated skin