What is the best approach for managing a patient with Dupuytren's contracture?

Management of Dupuytren's Contracture: SOAP Note

Subjective

• Patient presents with Dupuytren's contracture
• Symptoms include progressive contracture of fingers
• Limited hand function affecting daily activities
• History of previous treatments and their effectiveness should be documented

Objective

• Physical examination should focus on the degree of contracture at metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, as these respond differently to treatment 1
• Presence of palpable cords and nodules in the palmar fascia
• Measurement of fixed flexion contracture in degrees
• Assessment of functional limitations
• Tabletop test (inability to place palm flat on table)

Assessment

• Dupuytren's contracture requiring intervention
• Severity classification based on degree of contracture:
  • Mild: < 30 degrees
  • Moderate: 30-60 degrees
  • Severe: > 60 degrees 1, 2
• Differentiate from contractures caused by neurological conditions 1
• Consider association with liver disease if present 1

Plan

Non-surgical Management (First-line approach for mild to moderate cases)

• Daily static stretching exercises when pain and stiffness are minimal 1
• Application of superficial moist heat before exercises to improve effectiveness 1, 3
• Maintain terminal stretch position for 10-30 seconds before slowly returning to rest position 1, 3
• Resting hand/wrist splints combined with regular stretching 1, 2
• Consider collagenase Clostridium histolyticum (CCH) injections:
  • More effective for MCP joints (80% success) than PIP joints (39% success) 4
  • Requires passive manipulation the day after injection 5
  • Night extension splinting and home stretching exercises following injection 5
  • Monitor for recurrence within 2 years of treatment 5

Minimally Invasive Procedures (For moderate cases or when non-surgical approaches fail)

• Percutaneous needle aponeurotomy (PNA):
  • Higher patient satisfaction with fewer adverse events compared to fasciectomy 6
  • Higher recurrence rate than surgical options 6
  • Can be combined with ultrasound guidance and lidocaine injection for better outcomes 7
• CCH vs. PNA:
  • Similar clinical outcomes between the two procedures 6
  • CCH has notable transient adverse events but is effective 6

Surgical Management (For severe established contractures)

• Surgical release (fasciectomy) recommended for severe contractures that don't respond to conservative measures 1
• Consider for patients with functional limitations despite less invasive approaches 8

Follow-up Plan

• Reassess at 6 weeks, 4 months, 1 year, and 2 years post-treatment 5
• Monitor for recurrence, defined as increase in contracture of ≥20° after treatment 5
• Older patients and those with multiple digit involvement require closer monitoring due to higher recurrence rates 5

Patient Education

• Explain expected outcomes based on joint involvement (MCP joints respond better than PIP joints) 5, 4
• Discuss recurrence rates and need for potential retreatment 5, 6
• Emphasize importance of compliance with home exercise program and splinting 1, 3