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AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye 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
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
Editors: 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; Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
Dupuytren contracture, Dupuytren's contracture, Dupuytren's disease, Dupuytren disease, palmar fasciitis, palmar fibromatosis, Viking disease, metacarpophalangeal joint deformity, MCP joints, proximal interphalangeal joint deformity, PIP joints
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).
Related eMedicine topics:
Dupuytren Contracture [Dermatology]
Dupuytren Contracture [Orthopedic Surgery]
Dupuytren Contracture [Rheumatology]
Hand, Dupuytren Disease
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.1
Frequency
United States
This disorder is relatively common, particularly in older adults.
Some studies have suggested a higher prevalence of Dupuytren contracture among people with diabetes, or among individuals who smoke or abuse alcohol. However, a large retrospective study by Loos and colleagues on 2919 hands on which surgery had been performed revealed no statistically significant evidence that the occurrence of Dupuytren contracture could be correlated with the presence of diabetes, with alcoholism, or with smoking.2
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 most often seen in individuals older than 50 years.
History
Taking a thorough history from the patient often helps to exclude many other diagnostic considerations.3 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 in 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 fully extend the MCP joint(s); a decreased ability to fully extend the PIP joint(s) is sometimes 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 a 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.3
- 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 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 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, 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, because of the contractures, have difficulty grasping objects, 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.
- In some cases, trauma may accelerate or initiate the process.
- There is conflicting literature regarding whether Dupuytren contracture can be seen with increased frequency in patients with a variety of other conditions. One study indicates no significant increase in the occurrence of Dupuytren contracture in patients with diabetes or alcoholism or who engage in smoking.2 Another report, however, notes that Dupuytren contracture is associated with several conditions (eg, alcoholism, diabetes, epilepsy, pulmonary disease) and with smoking.4 Nonetheless, even if such associations exist, no clear causal relationship has been established in the literature.
Trigger Finger
Other Problems to Be Considered
A locked trigger finger may present with some similarities to Dupuytren contracture. Finger flexor contracture due to joint 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.
Lab Studies
- Generally, no laboratory studies are needed in the diagnosis of Dupuytren contracture.
Imaging Studies
- As a rule, radiography or other imaging studies are unnecessary.
Procedures
- Nonsurgical procedures do not appear to have a role in the diagnosis of 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.
Rehabilitation Program
Physical Therapy
Stretching with the application of heat and ultrasonographic waves 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 to use 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 (>30º)
- Any contracture of the PIP joint
- Surgical interventions consist mostly of fasciectomy.5 Complete extension of affected joints may be possible with earlier intervention.
- Surgical fasciectomy is the accepted treatment for 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.1
Consultations
- Surgical intervention may be appropriate in more severe cases. Consider surgical consultation with one of the following specialists:
- Plastic surgeon
- Orthopedic hand surgeon
Other Treatment
- 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 this compound might modify the progression of the disease.6
- Investigation of enzymatic fasciotomy using clostridial collagenase injection has shown potentially encouraging results. A prospective, randomized, double-blind, placebo-controlled trial by Badalamente and Hurst showed collagenase injections to be safe and effective, with a low recurrence rate; the authors proposed this as a viable, nonsurgical treatment option for Dupuytren contracture.7 Clostridial collagenase is thought to lyse and rupture excessive collagen deposition, which decreases the tensile strength of Dupuytren cords.8, 9
- Some researchers have started looking into nonsurgical treatment options for Dupuytren disease, investigating how reported cellular mediators affecting the disease's pathogenesis might be harnessed.1
- Myofibroblasts are the primary cell type in Dupuytren disease; 5-fluorouracil (5-FU) inhibits proliferation and myofibroblast differentiation in Dupuytren cell culture. Thus, 5-FU has a potential use as an adjuvant to reduce the rate of recurrence and contracture.1
- Hyperbaric oxygen is another theoretical therapeutic option. Fibroblast and myofibroblast production may cease if hypoxic conditions are reversed by high tissue oxygenation.1
- An in-office percutaneous needle aponeurotomy can be considered as an alternative to surgery.10
- A percutaneous needle fasciotomy has been developed by a team of French rheumatologists, with results comparable to traditional surgery.11
- It is hoped that further research will elucidate or more firmly establish the role of nonsurgical interventions (eg, injections and other previously mentioned therapies) in the treatment of Dupuytren contracture.
Because this condition is generally painless, analgesic medications usually are not required. No medications are known to decrease the progression of the contractures.
Further Outpatient Care
- Patients with mild Dupuytren disease can be monitored on an infrequent basis via a brief follow-up visit every 6-12 months. In addition to accurate measurement of the progression of the contractures, the follow-up also provides an opportunity to elicit a history of any functional deficits. Further, these visits allow assessment and discussion of the need for surgical referral.
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
- It is difficult to predict which patients may progress to the point of requiring surgical intervention. For patients 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; reassurance should be provided when appropriate.
Medical/Legal Pitfalls
- There are few legal pitfalls for this disorder other than a failure to inform the patient that surgery is the definitive treatment option.
Special Concerns
- Pregnancy
- There is no known association between Dupuytren contracture and pregnancy.
- This condition is relatively uncommon in women of childbearing age. In the event that such a patient requires treatment for Dupuytren contracture, 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.
Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the revision of this manuscript.
| Media file 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. |
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Media type: Photo
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- Bansal V, Naidu SH. Dupuytren's disease. Curr Opin Orthop. 2005;16(4):236-9.
- Loos B, Puschkin V, Horch RE. 50 years experience with Dupuytren's contracture in the Erlangen University Hospital--a retrospective analysis of 2919 operated hands from 1956 to 2006. BMC Musculoskelet Disord. 2007;8:60. [Medline]. [Full Text].
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- Hnanicek J, Cimburova M, Putova I, et al. Lack of association of iron metabolism and Dupuytren's disease. J Eur Acad Dermatol Venereol. Apr 2008;22(4):476-80. [Medline].
- Anwar MU, Al Ghazal SK, Boome RS. Results of surgical treatment of Dupuytren's disease in women: a review of 109 consecutive patients. J Hand Surg [Am]. Nov 2007;32(9):1423-8. [Medline].
- Ketchum LD, Donahue TK. The injection of nodules of Dupuytren's disease with triamcinolone acetonide. J Hand Surg [Am]. Nov 2000;25(6):1157-62. [Medline].
- Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture. J Hand Surg [Am]. Jul-Aug 2007;32(6):767-74. [Medline].
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- Starkweather KD, Lattuga S, Hurst LC, et al. Collagenase in the treatment of Dupuytren''s disease: an in vitro study. J Hand Surg [Am]. May 1996;21(3):490-5. [Medline].
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- Corrado A, Cantatore FP. [Dupuytren's disease. State of the art and therapeutic perspectives]. Reumatismo. Apr-Jun 2007;59(2):118-28. [Medline].
- Breen TF. Wrist and hand. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:99-138.
- Brinker MR, Miller MD. The adult hand. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:196-220.
- Dupuytren's disease. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:198-9.
- McGee DJ. Forearm, wrist and hand. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:168-215.
- Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.
Dupuytren Contracture excerpt Article Last Updated: May 27, 2008
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