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Dupuytren's Contracture
Essentials
- In Dupuytren's contracture the palmar aponeurosis is thickened and may cause progressive limitation of the finger extension (picture 1).
- -Assessment and intervention in specialized care are indicated if the patient finds the flexion contracture disturbing. The total degree of flexion contracture is usually about 30° in such cases.
Clinical picture
- The palmar aponeurosis is thickened and a progressive flexion contracture of a finger may develop.
- The contracture typically affects the fifth and the fourth finger, less frequently the third finger, and rarely other fingers.
- At first, there is only thickening of the palmar fascia. A progressive flexion contracture often develops in the course of years. Finally the finger may be so contracted that it touches the palm.
- One type of clinical presentation is for the skin on the palm to contract forming a hollow that is difficult to keep clean.
- Sometimes similar thickening is observed in the plantar fascia (Ledderhose disease http://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=EN&Expert=199251). Penile curvature (Peyronie disease Peyronie's Disease (Induratio Penis Plastica)) also belongs to the same family of diseases.
- The cause is unknown but a family history and diabetes are associated with the condition.
- The condition is most common in men who have passed middle age, and it is usually bilateral.
- The condition is common in white people and very rare in Asian people. It has been called the Viking disease because it is common in the Nordic countries.
- If the patient is susceptible to the condition, the palmar aponeurosis may become more palpable and flexion contracture may increase rapidly after sustaining a wound or other injury to the palm.
Treatment
- Treatment is based on correctly timed intervention. There are no conservative forms of treatment available.
- A hand surgeon should perform invasive treatment only when the flexion contracture is so severe that it clearly interferes with normal use of the hand (e.g. when putting on gloves, washing the face, putting the hand in the pocket, shaking hands).
- Patients usually find the condition disturbing when the total degree of flexion contracture is about 30°.
- Surgical treatment is indicated when there is a flexion contracture of more than 30° in the MP or PIP joint and this causes discomfort to the patient.
- The intervention consists of either cutting (sectioning) the scarred palmar fascial cord with a thick injection needle (needle fasciotomy) in the outpatient setting or excising the palmar fascia surgically in the operating room (fasciectomy, aponeurectomy).
- There is a risk of recurrence associated with both operations. After needle fasciotomy, recurrence is more likely but, on the other hand, the minimally invasive procedure is quite easy to repeat.
- Besides wound infection, injury to a digital nerve is the most common surgical complication.
- The functional outcome after both forms of treatment is usually good. If the contracture is very severe, arthrodesis or amputation of the finger may be the best option.
- One alternative to surgery has been using injectable collagenase to enzymatically dissolve the cord. The results have been mostly similar to those of needle fasciotomy. Availability of the drug may vary.
- Extension night splints may be used after interventions. There is insufficient evidence of their effect.
References
- Boe C, Blazar P, Iannuzzi N. Dupuytren Contractures: An Update of Recent Literature. J Hand Surg Am 2021;46(10):896-906. [PubMed]
- Tam L, Chung YY. Needle aponeurotomy for Dupuytren contracture: Effectiveness of postoperative night extension splinting. Plast Surg (Oakv) 2016;24(1):23-6. [PubMed]
- Byström M, Ibsen Sörensen A, Samuelsson K et al. Five-Year Results of a Randomized, Controlled Trial of Collagenase Treatment Compared With Needle Fasciotomy for Dupuytren Contracture. J Hand Surg Am 2022;47(3):211-217. [PubMed]