Contents
Introduction
Dupuytren’s Contracture is a progressive flexion deformity of the fingers, typically affecting the 4th (ring) finger. Also commonly affects the little finger, and rarely the middle finger. It is a result of contracture and fibrosis of the palmar aponeurosis.
- There is myofibroblast proliferation which results in altered collagen matrix, causing contracture and sickening of the palmar fascia
It is usually painless, and can affect one or both hands. It usually progresses very slowly over many years, and in some cases can severely limit function.
It typically occurs in individual with a genetic tendency of the disease, although alcohol intake is also an important contributing factor.
Epidemiology
- More common in men (10:1)
- Increases after age 45
- Tends only to affect those of Scandinavian and Northern European origin, as well as those from the Iberian peninsula and Japan.
- In men >60 from northern Europe, prevalence is about 25%
- UK prevalence is about 5%
- Most cases are mild and only a very mislay minority require surgery
Aetiology
- It is believed that in about 70% of cases it is the result of a genetic disorder whereby susceptible individuals who are subsequently exposed to further risk factors. These factors can include:
- Smoking (3x more common)
- High alcohol intake
- Most cases do not have a history of alcoholism
- Exposure to vibrating heavy machinery (2x risk)
- Manual work (small increase in risk)
- Hyperlipidaemia
- Liver disease
- Diabetes
- Epilepsy – it is not clear if this is due to the epilepsy or the medications used to treat it
Presentation
- Often a tender nodule on the palm is the first sign
- Deformity is progressive and follows later
- Pain subsides as it progresses
- Eventually the whole hand becomes arched, and there is contracture of the MCP and interphalangeal joints
- Bilateral in 45% of cases
- Unilateral cases are more often on the right regardless of dominant hand
- May also affect other areas of the body – including the feet, and the penis (Peyronie’s disease)
- Hueston’s table test
- This is positive when the patient is unable to place their hand palm-side down on a table top
- This occurs when there is >30 degrees of flexion deformity at the MCP
- The presence of knuckle pads indicates a poor prognosis – they often advance more quickly and should be referred sooner
Diagnosis is usually clinical.
Consider LFTs if suspicion of alcoholism, and HbA1c / fasting glucose if a suspicion of diabetes.
Differential diagnosis
- Trigger finger
- May be tricky to differentiate. The following are features NOT typically seen in Dupuytren’s but commonly seen in trigger finger:
- Tender nodule at the base of the finger
- Usually causing clicking or popping sensations when moving the finger
- Pain when moving the finger
- Symptoms often are worse after periods of inactivity – e.g. when first waking in the morning
- Ganglion
- Callus
- Ulnar nerve palsy
- Sarcoma (rare)
- Tumours of the tendon sheath (e.g. giant cell) – rare
Management
Most patients do not develop significant disease and no treatment is required. Reassure patients int he early stages that any pain associated with a nodule will resolve.
Patients with a positive Hueston’s test (see above) should be referred to a hand surgeon for assessment and intervention. Intervention aims to reduce disability – and thus is not indicated if not disability is present.
- Injectable collagenase – is a relatively new treatment that has been shown to be equally effective to surgery in early disease. However, it has a relapse rate of about 50%
- Radiotherapy – is also effective in early disease, but not in later disease
- Surgery is only indicated int he most severe cases. Multiple procedures are available, and non has been proven more effective than any other
- Closed fasciotomy (aka needle fasciotomy)
- Can be done under local anaesthesia
- Recurrence rate 50% at 5 years
- 1% risk of complications (nerve injury, tendon injury)
- Fasciectomy
- Various amounts of the contracted cord +/- the overlying skin are removed
- Can be done with a regional block or general anaesthetic
- Splinting and hand physiology after surgery produce better outcomes
- Higher risk of complications than a fasciotomy (up to 25% – including infection, haematoma, flap necrosis, carpal tunnel syndrome
- Finger amputation is only considered in very advanced late presentations
- Closed fasciotomy (aka needle fasciotomy)
- Surgery involves careful removal of the affected palmar aponeurosis around neurovascular bundles (which are left behind). Recurrence can occur particularly if the dissection for removal is not adequate, and/or commonly if the patient is young at the time of surgery
- Steroid Injections are no longer recommended and are not thought to be effective
- Splinting and physiotherapy are NOT effective
Dupuytren’s contracture post surgery
References
- Dupuytens Contracture – patient.info
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy