What are the assessment and treatment options for Dupuytren's contracture?

Assessment and Treatment of Dupuytren's Contracture

Dupuytren's contracture should be treated with a combination of non-surgical approaches for mild cases and surgical intervention for established contractures, with collagenase clostridium histolyticum (CCH) injection showing 70% success rates as a less invasive alternative to fasciectomy. 1, 2

Assessment

• Evaluate the degree of contracture by measuring passive extension deficit at metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints 2
• Identify palpable cords on the palmar surface of the hand 2
• Assess functional limitations in hand activities 1
• Document presence of nodules and their location 3
• Determine if contracture is ≥25° as this is predictive of recurrence after treatment 2

Non-Surgical Treatment Options

• Daily static stretching exercises when pain and stiffness are minimal 1
• Apply superficial moist heat before exercises to improve effectiveness 1
• Maintain terminal stretch position for 10-30 seconds before slowly returning to rest position 1
• Use resting hand/wrist splints combined with regular stretching 1
• Consider ultrasound-guided needle aponeurotomy combined with manual manipulation for less severe cases 4

Minimally Invasive Procedures

• Collagenase Clostridium Histolyticum (CCH) injection:
  • Indicated for adults with palpable cords 2
  • Success rate of approximately 70% with 25% recurrence rate 2
  • More effective for MCP joints (80% success) than PIP joints (39% success) 5
  • Requires no suture removal and allows for faster recovery 2
  • Can be repeated for recurrent contractures with 75% success rate 2
• Needle aponeurotomy:
  • Suitable for moderate contractures 3
  • Can be combined with lidocaine injections and manual manipulation 4
  • Less invasive than open surgery but may have higher recurrence rates 6

Surgical Treatment

• Limited fasciectomy:
  • Indicated for severe established contractures that don't respond to conservative measures 1
  • Shows 75% success rate for recurrent contractures after CCH treatment 2
  • Provides more durable results but requires longer rehabilitation 3
  • Standard of care for extensive contractures 3

Treatment Algorithm

1. For mild contractures (<25°) with minimal functional impairment:

   • Begin with stretching exercises, splinting, and heat therapy 1
   • Monitor for progression every 3-6 months 1

2. For moderate contractures (25-45°) affecting function:

   • Consider CCH injection or needle aponeurotomy 2, 3
   • CCH is particularly effective for MCP joint contractures 5

3. For severe contractures (>45°) or those not responding to minimally invasive approaches:

   • Limited fasciectomy is recommended 1, 3
   • More extensive surgical intervention may be required for recurrent cases 3

Follow-up and Monitoring

• Assess treatment success by measuring contracture reduction to ≤5° 5
• Monitor for recurrence, particularly in patients with pre-treatment contractures ≥25° 2
• Evaluate hand function and patient satisfaction after treatment 5
• Consider repeat CCH injections for recurrent contractures 2

Common Pitfalls and Caveats

• Distinguish Dupuytren's contracture from contractures caused by neurological conditions 1
• PIP joint contractures are more resistant to treatment than MCP joint contractures 5
• Patients should be counseled about potential recurrence rates with all treatment modalities 2, 3
• Consider patient factors such as recovery time needs and functional demands when selecting treatment approach 2