What is Dupuytren's contracture?

Dupuytren's Contracture: Diagnosis and Management

Dupuytren's contracture is a systemic connective tissue disorder characterized by abnormal proliferation of collagen in the palmar fascia, resulting in progressive flexion deformity of the fingers that can significantly impact hand function. 1, 2

Clinical Features and Diagnosis

• Dupuytren's contracture primarily affects men of Northern European or Caucasian origin over the age of 55, with incidence increasing with age 3, 4
• The condition manifests as a progressive contracture of the palmar and digital fascia, leading to flexion deformities of the fingers, particularly affecting the ring and little fingers 1, 2
• Physical examination reveals palpable nodules and cords in the palm, with eventual tethering and flexion of affected digits 1
• Dupuytren's contracture is often considered a sign of systemic disease and may be associated with other conditions including Ledderhose disease (plantar fibromatosis), Garrod knuckle pads, and Peyronie disease 4
• The diagnosis is typically made clinically through physical examination, with the Tubiana classification commonly used to document disease severity 3

Risk Factors and Associations

• Dupuytren's contracture is frequently associated with chronic alcohol consumption and may be observed during physical examination of patients with alcoholic liver disease 5
• It is considered one of the physical signs suggestive of harmful alcohol drinking, along with parotid gland hypertrophy, muscle wasting, and peripheral neuropathy 5
• Other risk factors include diabetes mellitus and tobacco use, which are associated with worse long-term outcomes after treatment 3
• The condition has a higher prevalence in patients with psoriasis and may share common genetic polymorphisms with certain skin malignancies 4

Treatment Options

Conservative Management

• Daily stretching exercises are recommended when pain and stiffness are minimal 6
• Applying superficial moist heat before exercises can improve effectiveness 6
• Maintaining terminal stretch position for 10-30 seconds before slowly returning to rest position is advised 6

Minimally Invasive Treatments

• Collagenase Clostridium histolyticum (CCH) injections represent a relatively new treatment method that has shown significant long-term improvements in contracture of both metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints 3, 2
• Long-term follow-up studies (average 5.7 years) show reduction in flexion contracture from 42° to 17° in MCP joints and from 56° to 33° in PIP joints after CCH treatment 3
• Percutaneous needle aponeurotomy (PNA) tends to provide higher patient satisfaction with fewer adverse events compared to limited fasciectomy, though with higher recurrence rates 7
• Recent comparative studies show no significant difference in clinical outcomes between PNA and CCH treatments 7

Surgical Intervention

• Surgical fasciectomy remains the traditional treatment for advanced contractures 1, 7
• Limited fasciectomy has shown similar success rates (75%) to repeat CCH injections for recurrent contractures 2
• Orthopedic surgery may be necessary in cases where progression exceeds what can be managed conservatively 6

Recurrence and Follow-up

• Primary recurrence rates after CCH treatment are approximately 11% for MCP joints and 19% for PIP joints 3
• Pre-injection contracture of ≥25° is predictive of recurrence after treatment 2
• Patients with diabetes and those who use tobacco have significantly worse long-term outcomes and higher recurrence rates 3
• Regular monitoring for associated skin conditions is recommended in all patients with Dupuytren's contracture 4

Special Considerations

• Positioning and appropriate orthotics should be used to counteract deforming forces when necessary 6
• The use of positioning devices and orthotics should be coordinated with medical specialists due to potential contraindications such as cardiovascular compromise or osteoporosis 6
• In the veteran and active duty population, CCH treatment can facilitate faster recovery and return to service compared to surgical options 2