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

Treatment of Dupuytren's Contracture

For Dupuytren's contracture, initiate daily static stretching exercises combined with moist heat for mild disease, progress to collagenase injection for moderate contractures (particularly MCP joints), and reserve surgical fasciectomy for severe contractures unresponsive to less invasive measures. 1, 2

Conservative Management (First-Line for Mild Disease)

• Perform daily static stretching exercises when pain and stiffness are minimal, ideally before bedtime, maintaining terminal stretch position for 10-30 seconds before slowly returning to rest position 1, 3
• Apply superficial moist heat before stretching exercises to improve tissue extensibility and effectiveness 1, 3
• Consider resting hand/wrist splints combined with regular stretching, though evidence for splints alone remains limited 1

Minimally Invasive Interventions (Second-Line for Moderate Contractures)

• Collagenase injection is the preferred treatment for moderate Dupuytren's contracture, particularly for MCP joint involvement, with 80% success rate for MCP joints (defined as contracture reduced to ≤5 degrees) versus 39% for PIP joints at 12 months 2
• Collagenase requires an average of 1.2 injections per patient and 0.8 injections per joint, with high patient satisfaction (VAS score 78/100) and no serious adverse events 2
• Percutaneous needle aponeurotomy represents an alternative minimally invasive option for mild to moderate contractures, though it carries higher recurrence rates compared to surgical options 4

Surgical Management (Reserved for Severe or Refractory Disease)

• Surgical fasciectomy is indicated for severe established contractures that fail conservative measures and minimally invasive treatments 1, 5
• Selective fasciectomy remains the most commonly performed procedure by hand surgeons for Dupuytren's disease 4
• Dermofasciectomy with full-thickness skin grafting is increasingly used for recurrent disease due to lower recurrence rates, particularly for severe PIP joint contractures exceeding 70 degrees 6, 4
• For severe PIP joint contractures (>70 degrees), staged procedures using external fixation combined with fasciectomy achieve 69% good-to-excellent results, though complications include pin site infections (8 cases in 38 fingers) 6

Treatment Algorithm by Severity

Mild contractures (minimal functional impairment):

• Daily stretching with moist heat application 1, 3
• Monitor progression with serial examinations

Moderate contractures (functional limitation present):

• Collagenase injection as primary intervention, especially for MCP joint involvement 2
• Consider percutaneous needle aponeurotomy as alternative 4

Severe contractures (significant functional impairment or failed conservative treatment):

• Surgical fasciectomy or dermofasciectomy 1, 5, 4
• Staged procedures with external fixation for severe PIP joint involvement (>70 degrees) 6

Critical Distinctions and Pitfalls

• Distinguish Dupuytren's contracture from neurological contractures, which present differently with spasticity and typically affect different muscle groups 1
• Dupuytren's contracture specifically involves palmar and digital fascia fibrosis, not muscle contracture from neurological conditions 7
• In patients with liver disease, presence of Dupuytren's contracture may suggest alcoholic etiology 1
• PIP joint contractures respond less favorably to collagenase (39% success) compared to MCP joints (80% success), requiring earlier consideration of surgical intervention 2