Dupuytren’s Contracture

Definition

• Benign, slowly progressive thickening and shortening of the Palmar Fascia
• May also affect the plantar fascia and penile corpus cavernosa (Peyronie’s Disease)

Epidemiology

• More common in males – 5-10: 1
• More common in Caucasians
• Increases with age (most > 50 yrs)
• Very common in Australia – 7% of population over 70

Pathophysiology

• Proliferation of fibroblasts (typically myofibroblasts which have contractile properties) and disordered deposition of collagen causing thickening of the Palmar Fascia
• Progresses to cause contractures of the MCP and PIP joints of the affected fingers
• Nodules contains Fibroblasts and type 3 collagen
• Typical of early proliferative phase of disease
• Increased fibrosis of overlying skin cause it to become attached, puckered and tethered to tendons below
• Tendons are, in fact, normal
• Progression is variable
  • Stages
    • Palmar pit or nodule
    • Palpable band/cord with no limitation of extension of either MCP or PIP
    • Lack of extension at MCP or PIP
    • Irreversible periarticular joint changes/scarring

Aetiology

• Exact aetiology unknown
• Autosomal dominant hereditary form exists
• Conditions associated with Dupuytren’s:
  • Diabetes
  • Epilepsy
  • Age (positive correlation)
• Family history (Autosomal dominant)/Fibromatoses
• Epileptic medication (e.g. Phenobarbitone)
• Smoking
• Trauma and Heavy Manual Labour
• Peyronie’s Disease (Fibrosis of Corpus Cavernosum – seen in 3% of Dupuytren’s)
• AIDS
• Idiopathic (most common)
• Liver disease (secondary to alcohol)

Differential Diagnosis

• Congenital:
  • Contracture of little finger – affects PIPJ
• Acquired:
  • Skin contracture
    • Look for scar from previous wounds
  • Tendon contracture
    • Thickened area, moves on passive flexion of involved finger
  • Trigger Finger
    • Flexion deformity of 4th finger but can be extended with excessive force from the patient or by passive extension (associated ‘snap’)
    • Finger and palmar skin will feel and look normal
    • Flexor tendon or tendon sheath may be thickened over the metacarpal head and a snap may be felt as the finger is flexed and extended
  • Ulnar Nerve Palsy
    • Clawing of 4th and 5th digits
    • Hyper-extension at MCPJ and flexion at PIPJ
    • Associated weakness of finger adduction/abduction and loss of sensation in distribution of ulnar nerve (5th finger and ulnar aspect of 4th)
    • Finger and palmar skin will feel and look normal
  • Palmar Fibromatosis
    • Rare condition associated with Ovarian malignancy (also stomach, pancreas, lung)
    • Progressive flexion deformities of all fingers of hand
    • Thickening of palmar skin and fascia similar to Dupuytren’s but more diffuse

Treatment

• Non-Operative:

  • Physiotherapy – stretching exercises for early forms

• Local Triamcinolone acetonide into fibrous nodules – may slow progression and injections into synovial sheaths treat episodes of tenosynovitis

  • Main complication: Tendon rupture

• Others:

  • Collagenase injections
  • External beam radiation

• Most of these confer mild-moderate benefits in early disease and all associated with high recurrence rates

• Operative:

  • Fasciotomy – Transection of fibrous bands
  • Partial Fasciectomy (with Z-plasty to lengthen wound): In conjunction with post-op physio (early active flexion range of motion exercises for grip strength) and night-time splintage in extension
    • Complications: Recurrence common
  • Dermofasciectomy (with full thickness skin grafting) – associated with lowest risk of recurrence
  • Arthrodesis/Amputation – for late presentations and repeat recurrences
  • Percutaneous needle fasciotomy – improves MCPJ and PIPJ contractures
    • But high rates of recurrence and poorer results compared to surgery