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Dupuytren Contracture

Basics

Description

  • Palmar fibromatosis: progressive fibrosis of palmar fascia → flexion deformity

  • Different from trigger finger (tendon sheath thickening)

  • Dupuytren diathesis = aggressive form with:

    • Onset <40 yrs

    • Bilateral hand involvement

    • Associated Ledderhose (plantar) & Peyronie disease

Epidemiology

  • Prevalence increases with age:

    • 55 yrs: 12%

    • 65 yrs: 21%

    • 75 yrs: 29%

  • High prevalence in Scandinavian men (e.g., Norway: 30% >60 yrs)

  • Male > Female (3.5:1 to 9:1)

  • Mean onset: 60 yrs (range 40–80 yrs)

Etiology & Pathophysiology

  • Unknown cause; proposed mechanisms:

    • Oxidative stress, immune dysfunction, wound healing anomalies

  • Luck Classification (3 stages):

    1. Proliferative: myofibroblast nodules

    2. Involutional: cord formation, ↑ type III collagen

    3. Residual: dense collagen & contracture

  • Genetics:

    • Autosomal dominant with incomplete penetrance

    • 68% of male relatives affected

    • Association with HLA alleles

Risk Factors

  • Age

  • Male sex

  • Caucasian/Northern European descent

  • Smoking (OR ~2.8)

  • Alcohol

  • DM (mild form, often middle/ring finger)

  • Manual work/vibration exposure

  • Family history

  • Hand trauma

  • Low BMI

Common Associations

  • Alcoholism

  • DM

  • Epilepsy

  • Chronic lung disease

  • HIV

  • Hypercholesterolemia

  • Carpal tunnel

  • Peyronie disease

  • Adhesive capsulitis

Diagnosis

History

  • Gradual onset of painless palm nodule

  • Loss of iADLs

  • Commonly affects ring/middle finger

  • MCP joint > PIP > DIP

Physical Exam

  • Triangular puckering over flexor tendon

  • Cord-like bands, nodules

  • Hueston Table Top Test: cannot flatten hand

  • Garrod nodes over knuckles

Staging – Tubiana

  • 0: No contracture

  • N: Nodule only

  • I: 1–45° contracture

  • II: 46–90°

  • III: 91–135°

  • IV: >135°

Differential Diagnosis

  • Camptodactyly

  • Diabetic cheiroarthropathy

  • Volkmann contracture

  • Trigger finger

  • Ganglion cyst

Imaging

  • Clinical diagnosis

  • MRI: may assess lesion recurrence risk post-surgery

Treatment

General Measures

  • Observation (mild)

  • Stretching, splinting

  • Physical therapy

First-Line Medication

  • Clostridial collagenase:

    • FDA-approved

    • Dissolves cords → manual rupture

    • Best for isolated MCP involvement

    • Recurrence ~47% at 5 years

  • Steroid injections:

    • Acute/painful nodules

    • Works best with needle aponeurotomy

    • 50% recurrence at 1–3 yrs

Second-Line

  • Extracorporeal shockwave therapy

Surgical/Procedure Options

Indications for Referral

  • PIP joint involvement

  • MCP >30° contracture

  • Impaired function

Procedures

Needle Fasciotomy

  • Best for MCP contractures

  • Recurrence: 50%

  • Comparable short-term results to collagenase

Limited Fasciectomy / Dermofasciectomy

  • Better long-term outcomes

  • Higher complication risk

  • Preferred in severe disease

  • May require skin grafting

PALF (Percutaneous Aponeurotomy + Lipofilling)

  • Minimally invasive

  • Similar 1-year results to fasciectomy

  • Less downtime

Amputation

  • Reserved for severe 5th digit deformity

Follow-up

  • Every 6–12 months

  • Educate: stretch fingers daily, avoid alcohol/manual work

  • Monitor recurrence (esp. in diathesis)

Prognosis

  • ~50% progress in 6 years (if untreated)

  • 10% regress spontaneously

  • Diathesis (early, bilateral, family hx, etc.) → ↑ recurrence (71% vs 23%)

  • Better outcomes in MCP than PIP joints

Complications

  • CRPS

  • Nerve injury

  • Edema, necrosis

  • Recurrence (46–80%)

  • Impaired function

  • Digital infarction

Clinical Pearls

  • Not the same as trigger finger

  • Both surgical and enzymatic options have high recurrence

  • Refer if PIP involved or MCP >30°

  • Monitor high-risk patients closely