You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
|
Dupuytren Contracture Last Updated: November 22, 2006 |
|
| Synonyms and related keywords: Dupuytren contracture, Dupuytren's disease, Dupuytren disease, palmar fasciitis, palmar fibromatosis, Viking disease, metacarpophalangeal joint deformity, MCP joints, proximal interphalangeal joint deformity, PIP joints
|
| |
AUTHOR INFORMATION
| Section 1 of 11   |
|
| Author: Patrick M Foye, MD, Assistant Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, UMDNJ, New Jersey Medical School Coauthor(s): Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation, Acting Director of Sports Medicine, UMDNJ-New Jersey School of Medicine; Lead Physician, Practice Medical Director of University Hospital PM & R Clinic |
| Patrick M Foye, MD, is a member of the following medical societies:
American Academy of Physical Medicine and Rehabilitation,
American Association of Neuromuscular and Electrodiagnostic Medicine,
Association of Academic Physiatrists, and
International Spine Intervention Society |
| Editor(s): Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine;
Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine;
Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center;
and Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research, Investigator, Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center |
Disclosure
| |
INTRODUCTION
| Section 2 of 11   |
|
Background: Dupuytren contracture results from contracture of the palmar fascia within the hand, possibly resulting in a fixed flexion deformity of the metacarpophalangeal (MCP) joints and the proximal interphalangeal (PIP) joints. This condition usually affects the fourth and fifth digits (the ring and small fingers). Pathophysiology: The palmar fascia within the hand may develop nodular hypertrophic degeneration of uncertain etiology. The dense nodular fascia may become adherent to the overlying skin as the hypertrophic degeneration progresses, sometimes extending distally into the involved digit. This anatomic change may result in contracture of the involved fascia, causing fixed flexion of the MCP joint and sometimes of the PIP joint as well. The most commonly affected area is the ulnar aspect of the hand (digits 4 and 5).
Myofibroblasts are the primary cell type in Dupuytren disease (Bansal, 2005). Frequency:
- In the US: This disorder is relatively common, particularly in older adults.
Mortality/Morbidity:
- No mortality is associated with this condition.
- As the contractures progress, the physical impairments may cause disability if the individual is unable to perform tasks requiring full use of all digits, particularly when the dominant hand is involved.
Race: Dupuytren contracture is seen more commonly in patients of northern European descent, hence the term Viking disease.
Sex: This condition affects men more often than women.
Age: This condition is usually seen among individuals older than 50 years.
History: Taking a thorough history from the patient often helps exclude many other diagnostic considerations. - A patient typically presents with a history of progressive loss of range of motion (ROM) of the affected finger(s), although fibrous contractures may appear elsewhere in the body, such as the plantar fascia, knuckle pads, and shaft of the penis.
- The fourth digit most commonly is involved. The fifth, third, and second fingers are involved in decreasing order of frequency. Specifically, there is a decreased ability to extend the MCP joint(s) fully, and sometimes a decreased ability to extend the PIP joint(s) fully is noted.
- The history may refer to an isolated nodule in this area, initially somewhat tender, which may have hardened and then disappeared.
- Asking about functional disabilities may elicit a history of certain tasks that the individual can no longer perform, such as grasping objects and typing.
- No sensory deficits are reported, unless there is some other concomitant pathology.
- The condition is painless in its later stages.
Physical: A careful physical examination often confirms the diagnosis without the need for further tests. - Examination reveals a palmar skin nodule, generally within the distal aspect of the palm.
- The nodularity generally is not tender to palpation.
- Puckering of the skin above the nodularity may be noted. Overlying skin may be adherent to the fascia, and a fibrous cord can extend into the finger.
- Flexion of the digit is normal for both passive and active ROM.
- Conversely, extension is limited at the MCP and sometimes the PIP joints of the affected digits. This limitation in finger extension occurs when testing both passive and active ROM.
- The ring finger (digit 4) is the most commonly involved site, followed by the small finger (digit 5). Other digits may be involved in some cases, although less commonly.
- Loss of progressive flexion of the fingers in the resting position from the radial to ulnar side may be noted.
- Although the patient may have difficulty grasping objects due to the contractures, strength is normal within the available ROM.
- Sensation is typically normal.
Causes: - Etiology includes a dominant genetic inheritance pattern that often involves individuals of northern European descent.
- Trauma may accelerate or initiate the process in some cases.
- Although a causal relationship has not been established, a number of conditions are associated with Dupuytren contracture (eg, alcoholism, diabetes, smoking, epilepsy, pulmonary disease).
| |
DIFFERENTIALS
| Section 4 of 11 |
|
Trigger Finger
Other Problems to be Considered:
A locked trigger finger may present with some similarities to Dupuytren contracture.
Finger flexor contracture due to either joint pathology or tendon pathology may cause a presentation similar to that of Dupuytren contracture; however, it is notable that, in Dupuytren contracture, the tendon is spared; only the fascia is involved. |
|
Patient Education
|
|
Click here for patient education.
|
|
|
|
|
Lab Studies:
- Generally, no laboratory studies are needed in diagnosing Dupuytren contracture.
Imaging Studies:
- As a rule, radiography or other imaging studies are unnecessary.
Procedures:
- Nonsurgical procedures do not appear to have a diagnostic role for this condition.
Histologic Findings: Nodular hypertrophic degeneration of the palmar fascia with adherence to the overlying skin is noted. Pathologically, the contracture consists of proliferating vascular fibrous tissue that later develops into mature collagen. Dermis typically is involved, resulting in fixation to the fascia.
| |
TREATMENT
| Section 6 of 11 |
|
Rehabilitation Program:
- Physical Therapy: Stretching with application of heat and ultrasound may be helpful in the early stages of Dupuytren contracture. The physical therapist also may recommend that the patient wear a custom splint or brace to stretch the fingers further. ROM exercises should be performed several times a day. If the patient undergoes surgical correction of the contracture, physical therapy often is involved following the procedure. The postsurgical program consists of wound care, massage, passive stretching, active ROM exercises, and splinting.
- Occupational Therapy: Through a course of occupational therapy, the patient may learn adaptive techniques and begin using assistive devices that enhance functional abilities. For example, adaptive equipment can help a patient to open jars, despite contractures.
Medical Issues/Complications: - The main complication is progressive impairment and disability secondary to continuing contracture.
Surgical Intervention: - A patient with mild disease can be tracked clinically for progression before considering surgical intervention.
- Consider surgical intervention for a patient with the following features:
- Significant functional disability secondary to this disease
- Significant MCP contracture (>30°)
- Any contracture of the PIP joint
- Surgical interventions consist mostly of fasciectomy. Complete extension of affected joints may be possible with earlier intervention.
- Surgical fasciectomy is the accepted treatment of Dupuytren disease; nonsurgical treatment options are either in their infancy or show little clinical efficacy. However, because surgery does not cure the disease and recurrence rates range from 26-80%, nonsurgical treatment options continue to be explored (Bansal, 2005).
Consultations: - Surgical intervention may be appropriate in more severe cases. Consider surgical consultation with one of the following specialists:
Other Treatment (injection, manipulation, etc.): - Intralesional corticosteroids injection may be helpful in the early stages of the disease.
- In a clinical trial in which nodules of Dupuytren disease were injected with triamcinolone acetonide, researchers concluded that triamcinolone acetonide might modify the progression of the disease (Ketchum, 2000).
- Recent investigation of enzymatic fasciotomy using clostridial collagenase injection has shown potentially encouraging results. Clostridial collagenase is thought to lyse and rupture excessive collagen deposition, which decreases the tensile strength of Dupuytren cords (Badalamente, 2002; Starkweather, 1996).
- Some researchers have started looking into nonsurgical treatment options for Dupuytren disease based on the more recently reported cellular mediators affecting the pathogenesis of Dupuytren disease and how these factors might be harnessed (Bansal, 2005).
- Myofibroblasts are the primary cell type in Dupuytren disease and 5-fluorouracil (5-FU) inhibits both proliferation and myofibroblast differentiation in Dupuytren cell culture. Thus, 5-FU has the potential of being used as an adjuvant to reduce the rate of recurrence and contracture (Bansal, 2005).
- Hyperbaric oxygen is another theoretical therapeutic option. Fibroblast and myofibroblast production may cease if hypoxic conditions are reversed by high tissue oxygenation (Bansal, 2005).
- Hopefully, further research will elucidate or more firmly establish the role of nonsurgical interventions (eg, injections and other treatments above) in the treatment of Dupuytren contracture.
| |
MEDICATION
| Section 7 of 11 |
|
Since this condition is generally painless, analgesic medications usually are not required. No medications are known to decrease the progression of the contractures.
| |
FOLLOW-UP
| Section 8 of 11 |
|
Further Outpatient Care:
- Patients with mild Dupuytren disease can be monitored on an infrequent basis with a brief follow-up visit every 6-12 months. In addition to accurate measurement of the progression of the contractures, the follow-up also allows an opportunity to elicit a history of any functional deficits. Further, these visits allow assessments and discussions regarding when surgical referral may be needed.
In/Out Patient Meds:
- No medications are known to decrease the symptoms or progression of this condition.
Complications:
- The predominant complication is progressive flexion contracture of the digits with associated functional disability.
Prognosis:
- Which patient may undergo progression to the point where surgical intervention is required is difficult to predict. For those who do require surgery, the postsurgical prognosis for recovery is good.
Patient Education:
- As with any medical condition, the patient should be informed thoroughly regarding the nature of the diagnosis; provide reassurance where appropriate.
| |
MISCELLANEOUS
| Section 9 of 11 |
|
Medical/Legal Pitfalls:
- Legal pitfalls are few for this disorder, other than a failure to inform the patient that surgery is the definitive treatment option.
Special Concerns:
- No association of this condition with pregnancy is known.
- This condition is relatively uncommon in women of childbearing age. In the event that such a patient requires treatment for this condition, defer this elective procedure until after the pregnancy.
- Pediatric population: This condition generally is not seen in children.
- Geriatric population: This condition is seen most commonly in elderly persons.
| |
PICTURES
| Section 10 of 11 |
|
| Caption: Picture 1. This photo shows a patient with an inability to extend the fourth and fifth digits. The differential diagnosis includes Dupuytren contracture, which is a flexion contracture most commonly involving digits 4 and/or 5.
|  |  View Full Size Image |
|
Picture Type: Photo |
| |
BIBLIOGRAPHY
| Section 11 of 11 |
|
-
Badalamente MA, Hurst LC, Hentz VR: Collagen as a clinical target: nonoperative treatment of Dupuytren's disease. J Hand Surg [Am] 2002 Sep; 27(5): 788-98[Medline].
-
Bansal V, Naidu SH: Dupuytren's disease. Current Opinion in Orthopaedics 2005; 16(4): 236-239.
-
Breen TF: Wrist and hand. In: Orthopaedics in Primary Care
. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1998:99-138.
-
Brinker MR, Miller MD: The adult hand. In: Fundamentals of Orthopaedics
. Philadelphia, Pa: WB Saunders; 1999:196-220.
-
Ketchum LD, Donahue TK: The injection of nodules of Dupuytren's disease with triamcinolone acetonide. J Hand Surg [Am]. 2000 Nov; 25(6): 1157-62.
-
McGee DJ: Forearm, wrist and hand. In: Orthopedic Physical Assessment
. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:168-215.
-
Snider RK: Dupuytren's disease. In: Essentials of Musculoskeletal Care
. 1st ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:198-9.
-
Starkweather KD, Lattuga S, Hurst LC, et al: Collagenase in the treatment of Dupuytren's disease: an in vitro study. J Hand Surg [Am] 1996 May; 21(3): 490-5[Medline].
-
Strakowski JA, Wiand JW, Johnson EW: Upper limb musculoskeletal pain syndromes. In: Physical Medicine and Rehabilitation
. 1st ed. Philadelphia, Pa: WB Saunders; 1996:756-82.
Dupuytren Contracture excerpt |
){kind=small}
