Abstract
Dupuytren’s contracture is a common complaint. Although it is initially painful, the pain seems to decrease as the condition progresses. As a result, patients suffering from Dupuytren’s contracture generally seek medical attention for functional disability rather than for pain.
Dupuytren’s contracture is caused by progressive fibrosis of the palmar fascia. Initially, the patient may notice fibrotic nodules along the course of the flexor tendons of the hand that are tender to palpation. As the disease advances, these nodules coalesce and form fibrous bands that gradually thicken and contract around the flexor tendons; this has the effect of drawing the affected fingers into flexion. Although any finger can develop Dupuytren’s contracture, the ring and little fingers are most commonly affected. If untreated, the fingers can develop permanent flexion contractures. The plantar fascia may be affected concurrently.
Dupuytren’s contracture is thought to have a genetic basis and occurs most frequently in male patients of northern Scandinavian descent. It has an autosomal-dominant inheritance pattern with variable penetrance. Siblings of patients suffering from Dupuytren’s contracture have three times the risk of developing the disease than the general population. Recent research has demonstrated that there are nine susceptibility loci with the strongest association with the clinical expression of the Dupuytren’s contracture located on an intron of EPDR1 , the gene responsible for encoding the ependymin-related 1 protein. The disease may also be associated with trauma to the palm, diabetes, alcoholism, anticonvulsants, and long-term barbiturate use. The disease rarely occurs before the fourth decade.
Keywords
Dupuytren’s contracture, genetic disease, progressive palmar fibrosis, progressive plantar fibrosis, flexion contracture, trigger finger, diagnostic sonography, ultrasound guided injection, collegenase clostridium histolyticum
ICD-10 CODE M72.0
The Clinical Syndrome
Dupuytren’s contracture is a common complaint. Although it is initially painful, the pain seems to decrease as the condition progresses. As a result, patients suffering from Dupuytren’s contracture generally seek medical attention for functional disability rather than for pain.
Dupuytren’s contracture is caused by progressive fibrosis of the palmar fascia. Initially, the patient may notice fibrotic nodules along the course of the flexor tendons of the hand that are tender to palpation. As the disease advances, these nodules coalesce and form fibrous bands that gradually thicken and contract around the flexor tendons; this has the effect of drawing the affected fingers into flexion. Although any finger can develop Dupuytren’s contracture, the ring and little fingers are most commonly affected ( Fig. 60.1 ). If untreated, the fingers can develop permanent flexion contractures. The plantar fascia may be affected concurrently.
Dupuytren’s contracture is thought to have a genetic basis and occurs most frequently in male patients of northern Scandinavian descent. It has an autosomal-dominant inheritance pattern with variable penetrance. Siblings of patients suffering from Dupuytren’s contracture have three times the risk of developing the disease than the general population. Recent research has demonstrated that there are nine susceptibility loci with the strongest association with the clinical expression of the Dupuytren’s contracture located on an intron of EPDR1 , the gene responsible for encoding the ependymin-related 1 protein. The disease may also be associated with trauma to the palm, diabetes, alcoholism, anticonvulsants, and long-term barbiturate use. The disease rarely occurs before the fourth decade.
Signs and Symptoms
In the early stages of the disease, hard fibrotic nodules known as Garrod’s pads along the path of the flexor tendons can be palpated. These nodules are often misdiagnosed as calluses or warts. At this early stage, pain is invariably present. As the disease progresses, taut fibrous bands form; they may cross the metacarpophalangeal joint and ultimately the proximal interphalangeal joint ( Fig. 60.2 ). These bands are not painful to palpation, and, although they limit finger extension, finger flexion remains relatively normal. At this point, patients often seek medical advice because of difficulty putting on gloves and reaching into their pockets. In the final stages of the disease, flexion contracture develops, with its negative impact on function. Arthritis, gout of the metacarpal and interphalangeal joints, and trigger finger may coexist with Dupuytren’s contracture and may exacerbate the patient’s pain and disability.
Testing
Plain radiographs are indicated for all patients who present with Dupuytren’s contracture, to rule out occult bony disease ( Fig. 60.3 ). Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, uric acid level, erythrocyte sedimentation rate, and antinuclear antibody testing. Magnetic resonance and ultrasound imaging of the hand are indicated if joint instability or tumor is suspected as well as to further evaluate the extent of the disease prior to surgical treatment ( Fig. 60.4 ). Electromyography is indicated if coexistent ulnar or carpal tunnel syndrome is a possibility.
