Dupuytren contracture is a common cause of hand pain and functional disability, which is most commonly caused by a progressive fibrosis of the palmar fascia, which was first described by Baron Guillaume Dupuytren in 1831. Early symptoms of Dupuytren contracture are tender fibrotic nodules along the course of the flexor tendons of the hand, although the nodules actually arise from the palmar fascia rather than the flexor tendons themselves. Although the ring and little fingers are most often affected, all fingers can develop the disease. As the disease progresses, these isolated nodules begin to coalesce and surround the flexor tendons, which draws the affected fingers into a characteristic posture of flexion (Fig. 78.1). Left untreated, the disease will progress until the affected fingers develop permanent flexion contractures, which cause significant functional disability. The pain of Dupuytren contracture tends to burn itself out as the disease progresses.

The exact cause of Dupuytren contracture remains unknown although the disease seems to have a genetic basis with an autosomal dominant inheritance pattern with variable penetrance. A biochemical pathogenesis has been hypothesized, which suggests that excess deposition of type I collagen combined with abnormal myofibroblast formation and increased levels of beta-catenin responsible for the disease. Dupuytren contracture occurs most commonly in males of northern European descent with a gender predilection approaching 10 males for every female affected. The disease rarely occurs before the fourth decade. Diabetes, smoking, cirrhosis of the liver, chronic barbiturate use, trauma to the palmar fascia, and alcoholism are risk factors.

Frequently, the painful, fibrotic nodules of the palmar surface that are seen early in the course of the disease are misdiagnosed as warts or ganglion cysts. As the disease progresses, taut, fibrous bands that may cross the metacarpophalangeal joint, and ultimately the proximal interphalangeal joint are noted on physical examination, clarifying the diagnosis (Fig. 78.2). These fibrous bands are not painful to palpation. As the functional disability associated with limitation of finger extension progresses, the patient will seek medical attention due to difficulty on putting on gloves or reaching into their pockets. Ultimately, permanent flexion contracture of the affected fingers results (Fig. 78.3).

Plain radiographs of the hand are indicated in all patients suspected of suffering from Dupuytren contracture to rule out occult bony pathology and to identify calcific tendinitis. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging or ultrasound imaging of the hand is indicated to assess the status of the affected tendons and tendon sheath as well as to identify other occult pathology including arthritis, sesamoiditis, and synovitis (Figs. 78.4, 78.5 and 78.6).

Dupuytren contracture is the result of the thickening of the palmar fascia and ultimately the effect this thickening has on the flexor tendons (see Fig. 78.1). The primary function of the palmar fascia, which is also known as the palmar aponeurosis, is to provide firm support to the overlying skin to aid the hand in gripping as well as to protect the underlying tendons.