What are the treatment options for a patient with Dupuytren contracture?

Treatment of Dupuytren's Contracture

For Dupuytren's contracture, begin with daily static stretching exercises and moist heat application for mild cases, progress to collagenase clostridium histolyticum (CCH) injection for moderate contractures with palpable cords, and reserve surgical fasciectomy for severe established contractures that fail conservative measures. 1

Conservative Management (First-Line for Mild Contractures)

• Daily static stretching exercises should be performed when pain and stiffness are minimal, preceded by superficial moist heat application to improve effectiveness 1
• Maintain the terminal stretch position for 10-30 seconds before slowly returning to rest position 1
• Resting hand/wrist splints may provide additional benefit when combined with regular stretching 1

Minimally Invasive Treatment (For Moderate Contractures)

Collagenase Clostridium Histolyticum (CCH) Injection

• CCH injection achieves 70% success rate (defined as contracture ≤5°) with an additional 20% showing improvement (≥20° reduction) 2
• This enzymatic treatment is specifically indicated for adults with palpable cords 2
• Success rates differ by joint: 80% for metacarpophalangeal (MCP) joints versus 39% for proximal interphalangeal (PIP) joints 3
• Requires an average of 1.2 injections per patient and 0.8 injections per joint 2
• Recurrence occurs in approximately 25% of cases, but repeat CCH treatment maintains 75% success rate 2
• Offers significant advantages in telemedicine era: no suture removal required, virtual motion assessment possible, and faster recovery with return to activity 2

Percutaneous Needle Aponeurotomy

• Provides good short-term results for mild to moderate contractures but carries a high recurrence rate 4
• Represents a minimally invasive alternative warranting consideration 4

Surgical Treatment (For Severe or Refractory Cases)

• Surgical release is indicated for severe established contractures that don't respond to conservative measures, with moderate evidence supporting effectiveness 1
• Selective fasciectomy remains the most commonly performed procedure by hand surgeons 4
• Dermofasciectomy is increasingly used for recurrent cases due to lower recurrence rates compared to standard fasciectomy 4
• For recurrent contractures treated surgically, range of motion improves by 23.31° for MCP joints and 15.49° for PIP joints 5

Treatment Algorithm by Severity

• Mild contractures without palpable cords: Conservative management with stretching and splinting 1
• Moderate contractures with palpable cords: CCH injection as primary treatment 2, 3
• Severe contractures or CCH failures: Surgical fasciectomy 1
• Recurrent disease: Repeat CCH injection (75% success) or dermofasciectomy for multiple recurrences 2, 4

Critical Predictive Factors

• Pre-treatment contracture ≥25° predicts higher recurrence risk regardless of treatment modality 2
• PIP joint involvement has significantly worse outcomes than MCP joint involvement across all treatment types 3

Important Clinical Distinctions

• Distinguish from neurological contractures, which present with different clinical patterns and associated neurological symptoms 1, 6
• In patients with liver disease, presence of Dupuytren's contracture may suggest alcoholic etiology 1, 6

Common Pitfalls to Avoid

• Avoid treating PIP joint contractures with same expectations as MCP joints—success rates are substantially lower (39% vs 80%) 3
• Don't dismiss CCH as inferior to surgery based solely on recurrence rates; the minimally invasive nature, lack of need for suture removal, and faster recovery make it preferable for appropriate candidates 2
• Pre-injection contracture severity must be assessed, as contractures ≥25° have significantly higher recurrence risk 2