What are the treatment options for Dupuytren's (Dupuytren's contracture) contracture?

Dupuytren's Contracture: Information, Risk Factors, and Treatment

Overview and Risk Factors

Dupuytren's contracture is a progressive fibroproliferative disorder causing flexion deformities of the fingers, most commonly affecting men over 60 of Scandinavian, Irish, or eastern European descent, with autosomal dominant inheritance. 1

Key Risk Factors:

• Age: Predominantly affects individuals over 60 years 1
• Ethnicity: Scandinavian, Irish, or eastern European descent 1
• Gender: More common in men 1
• Genetics: Autosomal dominant inheritance pattern 1
• Associated conditions: May be associated with alcoholic liver disease 2

Pathophysiology:

• Local microvessel ischemia in the hand triggers the disease process 1
• Platelet-derived and fibroblast growth factors promote dense myofibroblast populations 1
• Results in altered collagen profiles and progressive palmar fascial fibrosis 1

Clinical Presentation

The disease characteristically presents as firm nodularity on the palmar surface with coalescing cords affecting the webs and digits 3. Early disease is characterized by palmar nodules with limited or no contracture (not exceeding 30°, Tubiana grades N to 1) 4. Progressive disease leads to debilitating flexion contractures of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints 5.

Treatment Algorithm

Early Disease (Contracture <30°)

For early Dupuytren's disease, begin with conservative non-surgical management, though evidence for these interventions remains limited. 2, 4

Conservative Management:

• Daily static stretching exercises when pain and stiffness are minimal 2
• Apply superficial moist heat before exercises to improve effectiveness 2
• Maintain terminal stretch position for 10-30 seconds before slowly returning to rest position 2
• Resting hand/wrist splints may be beneficial when combined with regular stretching 2

Important caveat: The evidence for physical therapies in early disease is underpowered and provides insufficient evidence of efficacy, though these remain reasonable first-line approaches given their low risk 4.

Additional Options for Early Disease:

• Intralesional steroid injection may lead to softening of nodules and retard disease progression, though rigorous evaluation is lacking 4
• Radiotherapy appeared to retard disease progression in some studies but lacks rigorous evaluation 4

Established Contractures (≥30°)

Operative management is appropriate when MCP or PIP joint contracture exceeds 30 degrees. 1

Treatment Options by Severity:

For moderate contractures with satisfactory functional demands:

• Needle aponeurotomy (PNA): Minimally invasive with little downtime and moderate long-term efficacy 5, 6
• Collagenase Clostridium histolyticum (CCH) injection: Satisfactory results with moderate long-term efficacy 5, 6
• Ultrasound-guided needle aponeurotomy with lidocaine injection may provide dramatic relief 3

For extensive contractures or when durable results are required:

• Surgical palmar fasciectomy remains the mainstay treatment with the most durable long-term results 5, 6
• Use volar zigzag Brunner incision in the digit and palm for reliable exposure and predictable healing 1
• Consider full-thickness skin grafts for patients with Dupuytren's diathesis (early recurrence risk) 1

Postoperative Management

Critical postoperative care includes:

• Early active-flexion range-of-motion exercises to restore grip strength 1
• Nighttime extension splint for several months postoperatively to maintain correction 1
• Clear patient understanding of possible complications and considerable postoperative therapy commitment 1

Important Clinical Distinctions

Distinguish Dupuytren's contracture from contractures caused by neurological conditions, which typically have different presentations 2. Neurological contractures often involve spasticity and may benefit from different interventions including tizanidine, dantrolene, or oral baclofen 7.

Prognosis and Recurrence

Early recurrence is most common in individuals with Dupuytren's diathesis (characterized by early onset, bilateral disease, positive family history, and ectopic disease) 1. Surgical fasciectomy provides the most durable results for extensive contractures, while minimally invasive techniques (PNA, CCH) have moderate long-term efficacy with higher recurrence rates 5.