Dupuytren’s contracture

Published on 02/04/2015 by admin

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Last modified 22/04/2025

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219 Dupuytren’s contracture

Instruction

Look at this patient’s hands.

Salient features

History

• Family history (there is a genetic predisposition)

• Cigarette smoking (J Bone Joint Surg 1997;79B:206–10)

• Alcohol intake (Arch Intern Med 1977;129:561–6)

• Chronic antiepileptic medications

• Systemic conditions: cirrhosis, diabetes, TB, epilepsy.

Examination

• Thickening of the palmar fascia, particularly along the medial aspect (feel for thickening before you comment on it).

• In almost all cases, the fourth finger is affected with associated involvement of fifth, third and second fingers in decreasing order of frequency (Fig. 219.1).

• Perform the Hueston tabletop test: if the patient is unable to lay his or her palm flat on a tabletop, the test is positive.

• Tell the examiner that you would like to:

• check the feet for contracture of the plantar fascia (Fig. 219.2)
• look for signs of alcoholism and cirrhosis.
image

Fig. 219.1 Duputryen’s contracture.

image

Fig. 219.2 Ectopic deposits. (A) Bilateral medial plantar and medial great toe involvement. (B) Right foot involvement.

(With permission from Canale, Beaty 2007.)

Diagnosis

This patient has Dupuytren’s contracture (lesion) associated with chronic alcoholic liver disease (aetiology) and has developed disabling contractures (functional status). Be prepared to grade Dupuytren’s contracture (see below).

Advanced-level questions

What do you know about Dupuytren’s contracture?

It is caused by the thickening and shortening of palmar fascia; the plantar fascia may also be affected. Fibrous nodules are often the earliest abnormality and reflect contracture of the proliferating fibroblasts in the superficial compartment of the palm. The nodules consist of mature-appearing fibroblasts surrounded by dense collagen. Ultrastructurally, many of these cells are myofibroblasts and so may be contractile.

What other structures are involved?

There does not appear to be any direct involvement of the muscles, joints, tendons (and their sheaths), nervous tissue or vascular tissue. However, the dermis is frequently invaded by fibroblastic cells, resulting in fixation to deeper structures.

What are the grades of Dupuytren’s disease?

Grade 1 presents as a thickened nodule and a band in the palmar aponeurosis that may progress to skin tethering, puckering or pitting.

Grade 2 presents as a peritendinous band that limits extension of the affected finger.

Grade 3 presents as flexion contracture.

What is the natural history of this condition?

It is unpredictable, with little change or disability over a period of many years in some individuals. In others, the contraction of the fascia occurs rapidly, resulting in severe deformity and loss of hand function.

What do you know about the epidemiology of Dupuytren’s contracture?

There may be a hereditary predisposition (usually autosomal dominant) and the disorder is about five times more frequent in men, more common in whites and in Europe. There is a gradual increase in the incidence with age.

With which other conditions is Dupuytren’s contracture associated?

• Alcoholism

• Chronic antiepileptic therapy

• Systemic conditions such as cirrhosis, diabetes, epilepsy, TB

• Thickening of the corpora cavernosa of the penis (Peyronie’s disease)

• Garrod’s knuckle pads

• Retroperitoneal fibrosis.

Why is the deformity caused by this condition usually well tolerated?

Because it exaggerates the normal position of function of the hand.

How would you manage such patients?

Treatment depends on the severity of findings:

• Periodic examination of patients in early stages. If the palmar thickening is growing rapidly, local injections of triamcinolone into the growing nodule may be of benefit and reduce the need for surgery.

• Collagenase from Clostridium histolyticum, which lyses collagen and leads to disruption of contracted cords, is a new option for the therapy of advanced Dupuytren’s disease. Collagenase clostridium histolyticum significantly reduces contractures and improves the range of motion in joints affected by advanced Dupuytren’s disease. Therapy does not require anaesthesia. The collagenase is injected into the affected cord, and the treated joint is manipulated the next day to attempt cord rupture. Extensive hand therapy after treatment is not required (N Engl J Med 2009;361:968).

• Surgery is indicated when there are disabling flexion contractures (when the metacarpophalangeal joint contracture is >40 degrees or when the proximal interphalangeal joint contracture is >20 degrees), although recurrences are common (Lancet 1997;350:1568). The surgical procedures include open fasciectomy (the most common procedure), percutaneous or open fasciotomy, or needle fasciotomy.

F de la Peyronie (1678–1747), a French surgeon who influenced Louis XVI in his decision to issue an ordinance banning barbers from practising surgery.

Baron Guillaume Dupuytren (1777–1835), Surgeon-in-Chief, Hôtel-Dieu, Paris, is reported to have been the first to achieve successful removal of the lower jaw.

Sir AE Garrod (1857–1936), physician at St Bartholomew’s Hospital, London, succeeded Osler as Regius Professor at Oxford.

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