What are the management options for Dupuytren's contracture?

Management Options for Dupuytren's Contracture

The most effective management of Dupuytren's contracture requires a comprehensive approach including conservative measures for early or mild disease, with surgical intervention reserved for contractures exceeding 30 degrees at the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joints. 1, 2

Initial Assessment and Conservative Management

Non-surgical Options

• Daily stretching exercises: Should be performed multiple times daily to maintain joint mobility and prevent worsening of contractures 1
• Orthoses/splinting:
  • Resting hand/wrist splints for symptom relief, particularly for thumb base contractures 1
  • Night extension splints to maintain correction 2
• Positioning: Proper positioning of the hand to counteract deforming forces 1

When to Consider Intervention

• Progressive contracture development
• Functional limitation in daily activities
• Contracture exceeding 30 degrees at MCP or PIP joints 2

Interventional Treatment Options

1. Percutaneous Needle Aponeurotomy (PNA)

• Advantages:
  • Higher patient satisfaction
  • Fewer adverse events
  • Minimal downtime 3, 4
• Disadvantages:
  • Higher recurrence rate compared to fasciectomy 3
• Best for: Early disease, elderly patients, or those with medical comorbidities 4

2. Collagenase Clostridium Histolyticum (CCH) Injections

• Advantages:
  • Effective non-surgical option
  • Office-based procedure 3, 4
• Disadvantages:
  • Notable recurrence rates
  • High rate of transient adverse events including:
    • Local swelling
    • Bruising
    • Pain 3
• Best for: Patients seeking non-surgical treatment with moderate contractures 4

3. Surgical Fasciectomy

• Types:
  • Limited fasciectomy
  • Radical fasciectomy
  • Dermofasciectomy with skin grafting 5, 2
• Advantages:
  • Most durable results
  • Lower recurrence rates 4
• Disadvantages:
  • Longer recovery time
  • Higher complication rates
  • More extensive rehabilitation 5
• Best for: Severe contractures, recurrent disease, or young patients with aggressive disease 4, 6
• Surgical approach: Volar zigzag Brunner incision in the digit and palm provides reliable exposure 2

Post-Treatment Rehabilitation

After Surgery

• Early active-flexion range-of-motion exercises to restore grip strength 2
• Nighttime extension splinting for several months to maintain correction 2
• Regular follow-up adapted to individual patient needs 1

After Minimally Invasive Procedures

• Early mobilization
• Splinting as needed to maintain correction
• Monitoring for recurrence 5

Complications and Management

Common Complications

• Digital nerve and artery injury
• Flexor tendon injury
• Skin fissures and wound healing complications
• Hematoma
• Infection
• Flare reaction/complex regional pain syndrome
• Recurrence 5

Risk Factors for Recurrence

• Young age of onset
• Positive family history
• Presence of Dupuytren's diathesis (bilateral disease, ectopic lesions) 2, 6
• Full-thickness skin grafts may help reduce recurrence in high-risk patients 2

Special Considerations

Patient Selection Factors

• Age and overall health
• Severity of contracture
• Functional limitations
• Patient preferences and expectations 6
• Comorbidities (diabetes, seizure disorders) 6

Treatment Algorithm

1. Mild disease (no functional limitation, contracture <30°): Observation, stretching exercises, splinting
2. Moderate disease (functional limitation, contracture 30-60°): Consider PNA or CCH injection
3. Severe disease (significant functional limitation, contracture >60°): Surgical fasciectomy
4. Recurrent disease: Consider more extensive surgical approach (dermofasciectomy with skin grafting)

While there is currently no cure for Dupuytren's contracture, timely intervention with appropriate techniques can provide significant functional improvement for most patients 6.